DECLARATION OF CONFLICT OF INTEREST. None

Transcription

1 DECLARATION OF CONFLICT OF INTEREST None

2 How low should we go to avoid harm in hypertensives with comorbidities? CORONARY ARTERY DISEASE Prof. Dr. Maria DOROBANTU, FESC,FACC CARDIOLOGY EMERGENCY HOSPITAL OF BUCHAREST ROMANIA

3 N.R., male, 51 years Reason for admission: Retrosternal chest pain that started 2 hours before presentation to ER, constant, high intensity, no irradiation, accompanied by resting dyspnea.

4 History Severe hypertension for 10 years, not regularly treated (maximal P=220/120mmHg) Heavy smoker Dyslipidemia Peripheral artery disease Exertional angina for 6 years

5 ECG on admission

6 Echocardiography at bedside in the LVEDD=56mm CCU day 2 Extensive wall motion abnormalities, inferior and antero-lateral Global LVEF =35%

7 Coronary angiography

8 PTCA on the RCA

9 Medical treatment metoprolol 50 mg/day digoxin 1cp/day 5 days/week furosemide 20 mg/day zofenopril 15mg/day clopidogrel 75mg/day aspirin 300 mg/day rosuvastatine 10 mg/day

10 Clinical course First day: BP=128/70mmHg

11 2007 ESH/ESC Guidelines BP Targets (mmhg) by Treatment General hypertensive population < 140/90 (and lower values, if tolerated) High risk patients (CAD/cerebrovasc. disease/ diabetes/renal dysfunction) < 130/80 EHJ 2007;28:

12 Summary of target BP goals for patients with hypertension and CAD under the current AHA guidelines Clinical presentation BP target (mmhg) CAD equivalent (carotid, peripheral artery disease) < 130/80 10-y Framingham risk score 10% < 130/80 Stable angina < 130/80 Unstable angina/ non STEMI < 130/80 ST-elevation myocardial infarction < 130/80 Heart failure or LVEF < 40% < 120/80 Adapted from Rosendorff C, et al, Circulation 2007,115:

13 Clinical course Second day: Acute pulmonary edema with haemodinamic degradation cardiogenic shock (BP=70/50 mm Hg) Mitral regurgitation murmur Difficult clinical course, needed triple inotropic support (Dobutamine, Dopamine, Levosimendan), followed by digitalization

14 WHY THIS SEVERE CLINICAL COURSE? HOW DO WE TREAT THESE HYPERTENSIVE PATIENTS WITH PREVIOUS CAD? ARE NEW TARGETS FOR THESE PATIENTS NEEDED?

15 The linear theory lower is better has been challenged for nearly 3 decades, especially for diastolic pressure.

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17 Incidence of MI and Stroke Stratified by Diastolic Blood Pressure in the INVEST Study Messerli FH, Mancia G, Conti CR, et al. Ann Intern Med 2006;144:

18 Interaction of the J-Curve With Coronary Revascularization Messerli and Panjrath, JACC Vol. 54, No. 20, 2009:1831

19 Relative Risk for Primary / Selected Secondary Outcomes in ACCORD HR RR P Primary outcome Nonfatal MI Stroke CV death All cause death CHF Favours intensive therapy Favours standard therapy Intensive: SBP mmhg Standard: SBP mmhg Nilsson PM et al, abstract ESC 2010

20 Tight BP control and CV outcomes in patients with diabetes and CAD Cooper-DeHoff RM et al, JAMA. 2010;304(1):65

21 CV events and on-treatment DBP Active treatment No CHD at Baseline Active treatment CHD at Baseline P=.84 P<0.2 Diastolic BP, mmhg 0.5 Diastolic BP, mmhg Robert Fagard et al, Arch Intern Med. 2007;167(17):1887

22 CV events and DBP on placebo Placebo No CHD at Baseline 1.6 Placebo CHD at Baseline P<0.1 Diastolic BP, mmhg 0.6 P=.13 Diastolic BP, mmhg Robert Fagard et al, Arch Intern Med. 2007;167(17):1887

23 However prudent approach is warranted in patients with concomitant CAD in whom DBP should probably not be lowered to less than 70 mmhg R. Fagard

24 In contrast to any other vascular bed, the coronary circulation receives its perfusion mostly during diastole; An excessive decrease in diastolic pressure can significantly impair perfusion; In patients at risk, lowering blood pressure to levels that prevent stroke or renal disease might actually precipitate myocardial ischemia because of the adverse effect of too low diastolic pressure in coronary heart disease

25 ARE THESE TRUE ONLY FOR DBP? BUT FOR SBP?

26 J- curve revisited: an analysis of blood pressure and cardiovascular events in the Treating to new Targets (TNT) Trial Sripal Bangalore, Franz H. Messerli, Chuan-Chuan Wun, Andrea L. Zuckerman, David DeMicco, John B. Kostis, John C. la Rosa, Eur Heart J (2010) 31,

27 Analysis of blood pressure and CV events in TNT trial BP AND RISK OF PRIMARY OUTCOME Bangalore S, Eur Heart J (2010) 31,

28 Analysis of blood pressure and CV events in TNT trial BP AND NON-FATAL MI Bangalore S, Eur Heart J (2010) 31,

29 Analysis of blood pressure and CV events in TNT trial In patients with CAD, a low BP (, /,60 70 mmhg) portends an increased risk of future cardiovascular events (except stroke). Bangalore S, Eur Heart J (2010) 31,

30 What Is the Optimal Blood Pressure in Patient After Acute Coronary Syndromes? Relationship of blood pressure and Cardiovascular Events in the Pravastatin or Atorvastatin Evaluation and Infection Therapy Thrombolysis in Myocardial Infarction (PROVE IT-TIMI) 22 Trail. Sripal Bangalore, Jie Qin, Sarah Sloan, Sabina A. Murphy, Chrisopher P. Cannon, for PROVE IT-TIMI 22 Trail Invesigators, Circulation. 2010;122:2147

31 DBP AND SECONDARY OUTCOME IN PATIENTS WITH ACS (PROVE-IT TIMI 22 TRIAL) Bangalore S. et al, Circulation. 2010;122:2147

32 SBP AND SECONDARY OUTCOME IN PATIENTS WITH ACS (PROVE-IT TIMI 22 TRIAL) Bangalore S. et al, Circulation. 2010;122:2147

33 Incidence of the primary outcome (first occurrence of all-cause death, nonfatal myocardial infarction, or nonfatal stroke) by systolic blood pressure and diastolic blood pressure strata SBP DBP Messerli F et al, Ann Intern Med. 2006;144: , from the INVEST Study

34 Cardiac events (%) CV events (%) Adjusted HR CV events (%) CV events (%) Adjusted HR INVEST (CAD pts) 30 ONTARGET (high risk pts, mainly with CAD) >110 >120 to 120 to 130 >130 >140 to 140 to 150 to > On-treatment SBP (mmhg) > On-treatment SBP (mmhg) 0 30 VALUE (High risk pts) 35 TNT (CAD pts) < 120 >120 to 130 >130 to 140 >140 to 150 >150 to 160 On-treatment SBP (mmhg) >160 to 170 >170 to > 100 On-treatment DBP (mmhg) 0 Mancia G, ESH Annual Meeting, 2009

35 Mancia G et al, J of Hypertension 2009, 27:

36 ESH recommendations Based on current data, it may be prudent to recommend lowering SBP/DBP to values within the range /80-85 mmhg and possibly closer to lower values in this range, in all hypertensive patients. Mancia G et al, J Hypertension 2009, 27:2021

37 ESH Recomandation The recommendation of previous guidelines to aim at a lower goal SBP (<130mmHg) in diabetic patients and in patients at very high cardiovascular risk (previous cardiovascular events) may be wise, but it is not consistently supported by trial evidence. Mancia G et al, J Hypertension 2009, 27:2021

38 2009 European Guidelines Reappraisal In high-risk hypertensive patients, even intense cardiovascular drug therapy, though beneficial, is nonetheless unable to lower total cardiovascular risk below the high-risk threshold. Mancia G et al, J of Hypertension 2009, 27:

39 Blood pressure targets of antihypertensive treatment up and down the J-shaped curve. Alberto Zanchetti, European Heart Journal, (2010) 31,

40 In the absence of correctly designed trials all results are open to different and controversial interpretations Zanchetti A

41 Trials investigating the J curve Zanchetti A, European Heart Journal (2010) 31, 2839

42 Instead of conclusions New correctly designed randomized trials to different BP targets are needed. New hypertension guidelines are needed.

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44 Hypertensive patient with CAD AHA Recommendations Caution is advised in reducing DBP <60mmHg in diabetic patient over 60 years of age. In older hypertensive individuals with CAD and wide pulse pressures, lowering SBP could be dangerous by causing very low DBP values (< 60mmHg), with subsequent myocardial ischemia. Adapted from Rosendorff C, et al, Circulation 2007,115:

45 Anyhow, there is no consensus regarding the minimum safe level of DBP/SBP in hypertensive patients with CAD but BP should be lowered slowly by clinical judgment.

46 Thank you