ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest...

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ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ Ι.Ε.ΚΑΝΟΝΙΔΗΣ

Transcript of ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest...

Page 1: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ

Ι.Ε.ΚΑΝΟΝΙΔΗΣ

Page 2: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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 coronaryevent

• Every 60 seconds an American will die because of acoronary event

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

• 350000 people die per year because of a coronary event in theEmergency Department before even being admitted to thehospital

• Death Rate in 2001:

– 177 in 100,000

Page 3: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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 suddenlyvia CAD DID NOT HAVE ANY PREVIOUS SYMPTOMS

• Sudden Death:

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

Page 4: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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.

Page 5: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

Ηypertension

The estimated prevalence of hypertension in theUnited States in 2005 was :

• 35.3 million for men

• 38.3 million for women.

Hypertension is more prevalent in black personsthan in Hispanic and non-Hispanic whitepersons.

This prevalence is increasing.

Data from 1988-1994 and 1999-2002 demonstratedan increased prevalence of hypertension inblack individuals from 35.8% to 41.4%.

Page 6: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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Peripheral

vascular disease

Morbidity

Disability

Renal

disease

CADCHF

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

Page 7: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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Page 8: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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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

80–8975–79

70–74<70 <120

120–139

140–159

160+

Page 9: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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Risk of Cardiovascular Events by Hypertensive Status

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

9.5

3.3 2.45.0

2.03.5

2.1

45.4

21.3

12.4

6.2

9.97.3

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

DiseaseCardiac Failure

Bie

nn

ial A

ge

-Ad

jus

ted

Ra

te

pe

r 1

,00

0

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

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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

Page 11: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million
Page 12: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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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%

Page 13: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

INTERHEART study

About 25% of the

population-attributable risk of a myocardial

infarction can be accounted

for by hypertension

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Pathophysiological Association of hypertension

with IHD

• Endothelial dysfunction, which leads to the

developement of atherosclerosis,

• Increased afterload leading to myocardial

hypertrophy.

• Atherogenesis

• Hypertrophy

Page 15: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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.

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ECG -Hypertension

Electrocardiogram from a 46-year-old man with long-standinghypertension showing left atrial abnormality and leftventricular hypertrophy with strain.

Page 17: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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Blood Pressure Classification

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 HTN 140–159 or 90–99

Stage 2 HTN >160 or >100

BP Classification SBP mmHg DBP mmHg

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BHS classification of blood pressure levels

Category Systolic blood

pressure (mmHg)

Diastolic blood

pressure

(mmHg) Optimal blood pressure <120 <80

Normal blood pressure <130 <85

High-normal blood pressure 130-139 85-89

Grade 1 Hypertension (mild) 140-159 90-99

Grade 2 Hypertension (moderate) 160-179 100-109

Grade 3 Hypertension (severe) >180 >110

Isolated Systolic Hypertension (Grade 1) 140-159 <90

Isolated Systolic Hypertension (Grade 2) >160 <90

Page 19: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

Total Cardiovascular risk in Hypertensive Patients

Page 20: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

Treatment modalities in Hypertensive Patients

Page 21: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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

Page 22: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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

Page 23: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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

Page 24: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

Pharmacological Treatment in

Hypertension

Page 25: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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

Page 26: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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

Page 27: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

. 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 mm Hg in any patient with diabetes mellitus or who is

>60 years of age.

In older hypertensive individuals with wide pulse

pressures, lowering SBP may cause very low DBP values

(<60 mm Hg). This should alert the clinician to assess

carefully any untoward signs or symptoms, especially

those resulting from myocardial ischemia (Class Iia;Level

of Evidence: C).

Recommendations

Page 28: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million
Page 29: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million
Page 30: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

Best BP

CAMELOT

ACCORD

SPRINT

Page 31: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

Recommendations

1. The <140/90-mm Hg BP target is reasonable for

the secondary prevention of cardiovascular

events in patients with hypertension and CAD

(Class IIa; Level of Evidence: B).

2. A lower target BP (<130/80 mm Hg) may be

appropriate in some individuals with CAD,

previous MI, stroke or transient ischemic attack,

or CAD risk equivalents (carotid artery disease,

PAD, abdominal aortic aneurysm) (Class IIb;

Level of Evidence: B).

Page 32: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million
Page 33: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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

Page 34: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

• 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

Page 35: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

B-blockers

ACE Inhibitors

ARBBs

Diuretics

CCB

ΕΠΙΛΟΓΗ ΑΝΤΙΥΠΕΡΤΑΣΙΚΩΝ ΦΑΡΜΑΚΩΝ ΣΤΗΝ

ΔΕΥΤΕΡΟΓΕΝΝΗ ΠΡΟΛΗΨΗ ΣΤΕΦΑΝΙΑΙΑΣ ΝΟΣΟΥ

Page 36: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

THIAZIDES

• Veterans Administration

• MRC

• SHEP

• HYVET

Chlorothalidone

• ALLHAT

Diuretics in secondary prevention

Page 37: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

ARBs

• VALUE

• OPTIMAAL

• VALIANT

• TRANSCEND

Page 38: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

ACE Inhibitors in secondary prevention

• HOPE

• EUROPA

• PEACE

• ONTARGET

Page 39: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

CCB

• ALLHAT amlodipine VS diuretic or ACE

• ASCOT amlodipine VS b-blockers

• CONNICLE verapamil VS b-blockers or

diuretic

• INVEST verapamil VS

• NORDIL diltiazem VS b-blockers or diuretic

Page 40: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

1. Patients with hypertension and chronic stable angina should be

treated with a regimen that includes:

a) b-blocker in patients with a history of prior MI

b) An ACE inhibitor or ARB if there is prior MI, LV

systolic dysfunction, diabetes mellitus, or CKD; and

c) A thiazide or thiazide-like diuretic (Class I; Level of Evidence: A).

2. The combination of a b-blocker, an ACE inhibitor or

ARB, and a thiazide or thiazide-like diuretic should

also be considered in the absence of a prior MI, LV

systolic dysfunction, diabetes mellitus, or proteinuric

CKD (Class IIa; Level of Evidence: B).

3. If b-blockers are contraindicated or produce intolerable

side effects, a nondihydropyridine CCB (such as

diltiazem or verapamil) may be substituted, but not if

there is LV dysfunction (Class IIa; Level of Evidence: B).

Recommendations I

Page 41: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

4. If either the angina or the hypertension remains uncontrolled, a

long-acting dihydropyridine CCB can be added to

the basic regimen of b-blocker, ACE inhibitor, and thiazide or

thiazide-like diuretic.

The combination of a b-blocker and either of the nondihydropyridine

CCBs (diltiazem or verapamil) should be used with caution in

patients with symptomatic CAD and hypertension because of

the increased risk of significant bradyarrhythmias and HF

(Class IIa; Level of Evidence: B).

5. For patients with stable angina, the BP target is <140/

90 mm Hg. (Class I; Level of Evidence: A)

A lower target BP (<130/80 mm Hg) may be considered in

some individuals with CAD, with previous stroke or

transient ischemic attack, or with CAD risk equivalents

(carotid artery disease, PAD, abdominal aortic

aneurysm) (Class IIb; Level of Evidence: B). .

Recommendations II

Page 42: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

6. There are no special contraindications in hypertensive

patients for the use of antiplatelet or anticoagulant

drugs, except that in patients with uncontrolled severe

hypertension who are taking antiplatelet or

anticoagulant

drugs, the BP should be lowered without delay to

reduce the risk of hemorrhagic stroke (Class IIa; Level

of Evidence: C).

Antiplatelet or Anticoagulant drugs

Page 43: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

B-blockers

ACE Inhibitors

ARBBs

Diuretics

Nitates

ΕΠΙΛΟΓΗ ΑΝΤΙΥΠΕΡΤΑΣΙΚΩΝ ΦΑΡΜΑΚΩΝ

ΣΤΑ ΟΞΕΑ ΙΣΧΑΙΜΙΚΑ ΣΥΝΔΡΟΜΑ

Page 44: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

ACE inhibitors in ACS

• GISSI – 3

• ISSIS – 4

• CCS – 1

• ACE inh post ACS

Page 45: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

. Recommendations

1. If there is no contraindication to the use of b-blockers, in

patients with ACS, the initial therapy of hypertension should

include a short-acting b1-selective b-blocker without intrinsic

sympathomimetic activity (metoprolol tartrate or bisoprolol).

b-Blocker therapy should typically be initiated orally within 24

hours of presentation (Class I; Level of Evidence: A). For

patients with severe hypertension or ongoing ischemia,

an intravenous b-blocker (esmolol) can be considered

(Class IIa; Level of Evidence: B).

For hemodynamically unstable patients or when

decompensated HF exists, the initiation of b-blocker therapy

should be delayed until stabilization has been achieved (Class

I; Level of Evidence: A).

Page 46: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

2. In patients with ACS and hypertension,

nitratesshould be considered to lower BP or to

relieve ongoing ischemia or pulmonary

congestion (Class I; Level of Evidence: C).

Nitrates should be avoided in patients with

suspected right ventricular infarction and inthose

with hemodynamic instability. Sublingual or

intravenous nitroglycerin is preferred for initial

therapy and can be transitioned later to a longer-

acting preparation if indicated.

Page 47: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

3. If there is a contraindication to the use of a b-blocker or intolerable

side effects, then a nondihydropyridine CCB such as verapamil or

diltiazem may be substituted

for patients with ongoing ischemia, provided that LV dysfunction or

HF is not present. If the angina or hypertension is not controlled on a

b-blocker alone,

a longer-acting dihydropyridine CCB may be added

after optimal use of an ACE inhibitor (Class IIa; Level

of Evidence: B).

4. An ACE inhibitor (Class I; Level of Evidence: A) or an ARB (Class I;

Level of Evidence: B) should be added if the patient has an anterior

MI, if hypertension persists, if the patient has evidence of LV

dysfunction or

HF, or if the patient has diabetes mellitus. For lowerrisk

ACS patients with preserved LV ejection fraction

and no diabetes mellitus, ACE inhibitors can be

considered a first-line agent for BP control (Class IIa;

Level of Evidence: A).

Page 48: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

5. Aldosterone antagonists are indicated for patients who are already receiving b-

blockers and ACE inhibitors after MI and have LV dysfunction and either HF or

diabetes mellitus. Serum potassium levels must be monitored. These agents should be

avoided in patients with elevated serum creatinine levels (‡2.5 mg/dL in

men, ‡2.0 mg/dL in women) or elevated potassium levels (‡5.0 mEq/L) (Class I; Level of

Evidence: A).

6. Loop diuretics are preferred over thiazide and thiazide-type diuretics for patients with

ACS who have HF (NYHA class III or IV) or for patients with CKD and

an estimated glomerular filtration rate <30 mL/min.

For patients with persistent hypertension not controlled with a b-blocker, an ACE

inhibitor, and an aldosterone antagonist, a thiazide or thiazide-type

diuretic may be added in selected patients for BP

control (Class I; Level of Evidence: B).

7. The target BP is <140/90 mm Hg in patients with ACS who are hemodynamically

stable (Class IIa; Level ofEvidence: C)

. A BP target of <130/80 mm Hg at the time of hospital discharge is a reasonable option

(Class IIb;Level of Evidence: C).

The BP should be lowered slowly, and caution is advised to avoid decreases in

DBP to <60 mm Hg because this may reduce coronary perfusion and worsen ischemia.

Page 49: ΥΠΕΡΤΑΣΗ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ · CAD: Statistics • CAD is the largest killer of American males and females • 13 million Americans have CAD • 1.1 million

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