SPRINT trial: quoi de neuf en hypertension? Approche pratique du patient cardiaque en médecine 17 ème édition du Congrès de la Ligue Cardiologique Belge 21 mai 2016 générale Philippe van de Borne Service de Cardiologie ULB Hôpital Erasme Bruxelles
SPRINT SPRINT trial: quoi de neuf en hypertension? LES RECOMMENDATIONS DETRACTEURS DE SPRINT DONNES RECENTES: HOPE3 MAIS: - «méta- analyses» - épidémiologie - physiopathologie En conclusion
SPRINT SPRINT trial: quoi de neuf en hypertension? LES RECOMMENDATIONS DETRACTEURS DE SPRINT DONNES RECENTES: HOPE3 MAIS: - «méta- analyses» - épidémiologie - physiopathologie En conclusion
N Engl J Med Volume 373(22):2103-2116 November 26, 2015 The SPRINT Research Group A Randomized Trial of Intensive versus Standard Blood-Pressure Control Patients at increased cardiovascular risk but without diabetes: target systolic BP <120 mm Hg (intensive) or <140 mm Hg (standard). The protocol encouraged the use of drug classes with the strongest evidence for reduction in cardiovascular outcomes
Composite of myocardial infarction, acute coronary syndrome, stroke, heart failure, or death from cardiovascular causes Not included in this study: diabetes, prior stroke, <50 yrs The SPRINT Research Group. N Engl J Med 2015;373:2103-2116
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SPRINT SPRINT trial: quoi de neuf en hypertension? LES RECOMMENDATIONS DETRACTEURS DE SPRINT DONNES RECENTES: HOPE3 MAIS: - «méta- analyses» - épidémiologie - physiopathologie En conclusion
Comparison of Hypertension Guidelines 2011-2014 Blood pressure in mm Hg Definition of Hypertension Drug therapy in low risk patients after nonpharmacologic treatment NICE 2011[2] 140/90 and daytime ABPM (or home BP) 135/85 160/100 or day-time ABPM 150/95 ESH/ESC 2013[3] ASH/ISH 2014 [4] Go A. et al. AHA/ ACC/CDC 2013 [5] 2014 Hypertension guidelines, US JNC 8 [6] 140/90 140/90 140/90 Not addressed 140/90 140/90 140/90 < 60 y. 140/90 60 y. 150/90 Beta-blockers as first line drug No (Step 4) Yes No (Step 4) No (Step 3) No (Step 4) Diuretic chlorthalidone, indapamide thiazides chlorthalidone, indapamide thiazides chlorthalidone indapamide thiazides thiazides chlorthalidone, indapamide Initiate drug therapy with two drugs Not mentioned Blood pressure targets < 140/90 In patients with markedly elevated BP <140/90 160/100 160/100 160/100 <140/90 <140/90 < 60 y. <140/90 80 y. < 150/90 Elderly < 80 y. SBP 140-150 SBP <140 in fit patients Elderly 80 y. SBP 140-150 80 y. < 150/90 Lower targets may be appropriate in some patients, including the elderly 60 y. <150/90 Blood Pressure target in patients with diabetes mellitus Not addressed < 140/85 <140/90 <140/90 Lower targets may be considered <140 /90 Lindholm LH, Carlberg B. HT News 2014, Opus 35
Comparison of Hypertension Guidelines 2011-2014 Blood pressure in mm Hg Definition of Hypertension Drug therapy in low risk patients after nonpharmacologic treatment NICE 2011[2] 140/90 and daytime ABPM (or home BP) 135/85 160/100 or day-time ABPM 150/95 ESH/ESC 2013[3] ASH/ISH 2014 [4] Go A. et al. AHA/ ACC/CDC 2013 [5] 2014 Hypertension guidelines, US JNC 8 [6] 140/90 140/90 140/90 Not addressed 140/90 140/90 140/90 < 60 y. 140/90 60 y. 150/90 Beta-blockers as first line No Yes No No No drug (Step 4) (Step 4) (Step 3) (Step 4) Diuretic OBJECTIF chlorthalidone, THERAPEUTIQUE thiazides thiazides thiazides le plus strict: thiazides indapamide chlorthalidone, chlorthalidone chlorthalidone, indapamide Initiate drug therapy with two drugs Not mentioned Blood pressure targets < 140/90 HTA A PARTIR de: >140 et/ou >90 mm Hg <140 et/ou < 85 mmhg In patients with markedly elevated BP <140/90 160/100 160/100 160/100 <140/90 <140/90 < 60 y. <140/90 80 y. < 150/90 Elderly < 80 y. SBP 140-150 SBP <140 in fit patients Elderly 80 y. SBP 140-150 80 y. < 150/90 Lower targets may be appropriate in some patients, including the elderly 60 y. <150/90 Blood Pressure target in patients with diabetes mellitus Not addressed < 140/85 <140/90 <140/90 Lower targets may be considered <140 /90 Lindholm LH, Carlberg B. HT News 2014, Opus 35
Blood Pressure J-Curve: Current Concepts Maciej Banach & Wilbert S. Aronow Curr Hypertens Rep (2012) 14:556 566 The blood pressure (BP) J-curve debate started in 1979,
SPRINT SPRINT trial: quoi de neuf en hypertension? LES RECOMMENDATIONS DETRACTEURS DE SPRINT DONNES RECENTES: HOPE3 MAIS: - «méta- analyses» - épidémiologie - physiopathologie En conclusion
Hypertension. 2016 May;67(5):808-12. Overall, it means that the lower treatment arm in SPRINT translates into SBP <136 mm Hg, which is not very different from SBP <140 mm Hg, which is the currently recommended SBP target by all guidelines. The BP measurement technique in SPRINT is different from ACCORD, SPS3, and HOT, since other people were out of the room during measurements and the entire resting period before measurement.
SPRINT SPRINT trial: quoi de neuf en hypertension? LES RECOMMENDATIONS DETRACTEURS DE SPRINT DONNES RECENTES: HOPE3 MAIS: - «méta- analyses» - épidémiologie - physiopathologie En conclusion
12,705 participants at intermediate risk who did not have cardiovascular disease received 16/12,5 mg candesartan/hct or placebo o.d. composite of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke HOPE-3 published on April 2, 2016, at NEJM.org.
SPRINT SPRINT trial: quoi de neuf en hypertension? LES RECOMMENDATIONS DETRACTEURS DE SPRINT DONNES RECENTES: HOPE3 MAIS: - «méta- analyses» - épidémiologie - physiopathologie En conclusion
We identified 123 studies with 613 815 participants for the tabular meta-analysis...
SPRINT SPRINT trial: quoi de neuf en hypertension? LES RECOMMENDATIONS DETRACTEURS DE SPRINT DONNES RECENTES: HOPE3 MAIS: - «méta- analyses» - épidémiologie - physiopathologie En conclusion
SPRINT SPRINT trial: quoi de neuf en hypertension? LES RECOMMENDATIONS DETRACTEURS DE SPRINT DONNES RECENTES: HOPE3 MAIS: - «méta- analyses» - épidémiologie - physiopathologie En conclusion
Coronary blood flow in normotensive patients (white circles), hypertensive patients without left ventricular hypertrophy (squares) and hypertensive patients with left ventricular hypertrophy (black circles). Polese A, De Cesare N, Montorsi P, Fabbiocchi F, Guazzi M, Loaldi A, Guazzi MD. Upward shift of the lower range of coronary flow autoregulation in hypertensive patients with hypertrophy of the left ventricle. Circulation. 1991;83:845 853.
SPRINT SPRINT trial: quoi de neuf en hypertension? LES RECOMMENDATIONS DETRACTEURS DE SPRINT DONNES RECENTES: HOPE3 MAIS: - «méta- analyses» - épidémiologie - physiopathologie En conclusion
Coronary artery disease Acute coronary syndrome Heart failure Coronary artery disease
MERCI Approche pour votre pratique attention! du patient cardiaque en médecine 17 ème édition du Congrès de la Ligue Cardiologique Belge générale 21 mai 2016 Philippe van de Borne Service de Cardiologie ULB Hôpital Erasme Bruxelles