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  • ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ

    Ι.Ε.ΚΑΝΟΝΙΔΗΣ

  • CAD: Statistics

    • CAD is the largest killer of American males and females

    • 13 million Americans have CAD

    • 1.1 million MI’s per year

    • Every 26 seconds  an American will suffer from a coronary event

    • Every 60 seconds  an American will die because of a coronary event

    • 42% of those having a coronary event will die from it

    • 350000 people die per year because of a coronary event in the Emergency Department before even being admitted to the hospital

    • Death Rate in 2001:

    – 177 in 100,000

  • CAD: Demographics and Statistics

    • 84% of those who die from CAD are 65 or older

    • Within 1 year of initial MI:

    – 25% of men and 38% of women will die

    • Within 8 years of initial MI:

    • 50% of men and women under 65 will die

    • An average of 11.5 years of life are lost due to an MI

    • IMPORTANT:

    – 50% of men and 64% of women who have died suddenly via CAD DID NOT HAVE ANY PREVIOUS SYMPTOMS

    • Sudden Death:

    – Those with a previous history of MI have a 5-6 times Sudden Death rate compared to the general population

  • Hypertension

    • Hypertension( HTN) is the most common primary diagnosis in America.

    • 35 million office visits are as the primary diagnosis of HTN.

    • 50 million or more Americans have high BP.

    • Worldwide prevalence estimates for HTN may be as much as 1 billion.

    • 7.1 million deaths per year may be attributable to hypertension.

  • Ηypertension

    The estimated prevalence of hypertension in the United States in 2005 was :

    • 35.3 million for men

    • 38.3 million for women.

    Hypertension is more prevalent in black persons than in Hispanic and non-Hispanic white persons.

    This prevalence is increasing.

    Data from 1988-1994 and 1999-2002 demonstrated an increased prevalence of hypertension in black individuals from 35.8% to 41.4%.

  • 6

    Peripheral

    vascular disease

    Morbidity

    Disability

    Renal

    disease

    CAD CHF

    LVHStroke

    Hypertension

    National High Blood Pressure Education Program Working Group. Arch Intern Med. 1993;153:186-208.

    Hypertension: A Significant CV and Renal Disease Risk Factor

  • 7

  • 8

    Hypertension and CHD : (MRFIT)

    Adapted from Neaton JD et al. Arch Intern Med. 1992;152:56-64.

    SBP versus DBP in Risk of CHD Mortality

    Diastolic BP

    (mm Hg)

    Systolic BP

    (mm Hg)

    CHD Death Rate

    100+ 90–99

    80–89 75–79

    70–74

  • 9

    Risk of Cardiovascular Events by Hypertensive Status

    36-Year Follow-up in Patients Aged 35-64 Years

    9.5

    3.3 2.4 5.0

    2.0 3.5

    2.1

    45.4

    21.3

    12.4

    6.2

    9.9 7.3

    13.9

    6.3

    22.7

    0

    10

    20

    30

    40

    50

    Men Women Men Women Men Women Men Women

    Normotensive

    Hypertensive

    Coronary Disease Stroke Peripheral Arterial

    Disease Cardiac Failure

    B ie

    n n

    ia l A

    g e

    -A d

    ju s

    te d

    R a

    te

    p e

    r 1

    ,0 0

    0

    Reprinted with permission from Kannel WB. JAMA. 1996;275:1571-1576.

  • 10

    Disease Relative Risk

    Kidney failure (ESRD) 2.8

    Stroke 2.7

    Heart failure 1.5

    Peripheral vascular disease 1.8

    Myocardial infarction* =1.6

    Coronary artery disease 1.5

    ESRD = end-stage renal disease; SBP 165 mm Hg.

    *Men only.

    Adapted from Kannel WB. Am J Hypertens. 2000;13:3S-10S; Perry HM Jr et al. Hypertension. 1995;25(part 1):587-594;

    Klag MJ et al. N Engl J Med. 1996;334:13-18; Nielsen WB et al. Ugeskr Laeger. 1996;158:3779-3783; Neaton JD et al.

    Arch Intern Med. 1992;152:56-64.

    Elevated SBP Alone Is Associated With Increased Risk of Cardiovascular and Renal Disease

  • 12

    Benefits of Lowering BP

    Average Percent Reduction

    Stroke incidence 35–40%

    Myocardial infarction 20–25%

    Heart failure 50%

    TROPHY Study ACC 2006:

    Even lowering BP in those with pre-HTN appears to reduce incidence of new HTN by up to 60%

  • INTERHEART study

    About 25% of the

    population-attributable risk of a myocardial

    infarction can be accounted

    for by hypertension

  • Pathophysiological Association of hypertension

    with IHD

    • Endothelial dysfunction, which leads to the

    developement of atherosclerosis,

    • Increased afterload leading to myocardial

    hypertrophy.

    • Atherogenesis

    • Hypertrophy

  • LVH

    The rate of LVH based on ECG findings

     2.9% for men

     1.5% for women.

    based on echocardiographic findings

    15-20%

    33% of patients without LVH have evidence

    of asymptomatic LV diastolicdysfunction.

  • ECG -Hypertension

    Electrocardiogram from a 46-year-old man with long-standing hypertension showing left atrial abnormality and left ventricular hypertrophy with strain.

  • 17

    Blood Pressure Classification

    Normal 100

    BP Classification SBP mmHg DBP mmHg

  • BHS classification of blood pressure levels

    Category Systolic blood

    pressure (mmHg)

    Diastolic blood

    pressure

    (mmHg) Optimal blood pressure

  • Total Cardiovascular risk in Hypertensive Patients

  • Treatment modalities in Hypertensive Patients

  • Non pharmacological Treatment

    of hypertension and lifestyle changes

    • Lose weight, if overweight

    • Increase physical activity

    • Reduce salt intake

    • Stop smoking

    • Limit intake of foods rich in fats and cholesterol

    • Increase consumption of fruits and vegetables

    • Limit alcohol intake

  • Lifestyle Modification

    Modification Approximate SBP reduction (range)

    Weight reduction 5–20 mmHg / 10 kg weight loss

    Adopt DASH eating plan

    8–14 mmHg

    Dietary sodium reduction

    2–8 mmHg

    Physical activity

    4–9 mmHg

    Moderation of alcohol consumption

    2–4 mmHg

  • Drug therapy for hypertension

    Class of drug Example dose Initiating dose Usualmaintenance

    Diuretics Hydrochlorothiazide 12.5 mg o.d. 12.5-25 mg o.d.

    -blockers Atenolol 25-50 mg o.d. 50-100 mg o.d.

    Calcium Amlodipine 2.5-5 mg o.d. 5-10 mg o.d.

    channel

    blockers

    -blockers prazosin 2.5 mg o.d 2.5-10mg o.d.

    ACE- inhibitors ramipril 1.25-5 mg o.d. 5-20 mg o.d.

    Angiotensin-II Losartan 25-50 mg o.d. 50-100 mg o.d.

    receptor blockers

  • Pharmacological Treatment in

    Hypertension

  • INVEST

    TNT

    SMART

    • In favor

    Stewart Lancet 1979

    Cruickshank et al Lancet 1987

    Miller Hypertension 2000

    • Against

    Farnett et al JAMA 1991

    McMahon et al Lancet 1990

    J-Curve in HTN plus CAD

    J-Curve

  • HOT Study: Significant Benefit From

    Intensive Treatment in the Diabetic Subgroup

    Hansson L et al. Lancet. 1998;351:1755-1762.

    0

    5

    10

    15

    20

    25

    90 85 80

    Major

    cardiovascular

    events/1,000

    patient-years

    p=0.005 for trend

    mm Hg

    Target Diastolic Blood Pressure

  • . In patients with an elevated DBP and CAD with evidence

    of myocardial ischemia, the BP should be lowered slowly,

    and caution is advised in inducing decreases in DBP to

    60 years of age.

    In older hypertensive individuals with wide pulse

    pressures, lowering SBP may cause very low DBP values

    (

  • Best BP

    CAMELOT

    ACCORD

    SPRINT

  • Recommendations

    1. The

  • Treatment of BP in pts with IHD

    • Treatment of BP in primary prevention of IHD

    • Treatment of BP in secondary prevention of

    IHD

    • Treatment of BP in established IHD

    • Treatment of BP in ACS

  • • Δεν υπάρχει διαφορά μεταξύ των διαφόρων

    κατηγοριών αντιυπερτασικών φαρμάκων στην

    πρωτογενή πρόληψη, όσον αφορά την

    επίπτωση της στεφανιαίας νόσου και των

    καρδιαγγειακών επιπλοκών γενικώτερα.

    ΕΠΙΛΟΓΗ ΑΝΤΙΥΠΕΡΤΑΣΙΚΩΝ ΦΑΡΜΑΚΩΝ ΣΤΗΝ

    ΠΡΩΤΟΓΕΝΝΗ ΠΡΟΛΗΨΗ ΣΤΕΦΑΝΙΑΙΑΣ ΝΟΣΟΥ

  • B-blockers

    ACE Inhibitors