1. ©2011 MFMER | slide-1 Hipertensión Arterial Sistémica: Enfoque del Cardiólogo Jorge F. Trejo, MD, MHS Congreso Anual de Cardiología Internacional Guadalajara, Jalisco, Febrero 23, 2012

2. ©2011 MFMER | slide-2 145 140 135 130 125 Control diet DASH diet -8.0 (-4.9 to -11.1) -1.6 (0.6 to -3.8) -5.1 (3.0 to -7.3) -2.1 (0.1 to -4.0) -7.5 (-4.2 to -10.8) Higher to lower sodium Control: -8 DASH: -7 -6.0 (4.0 to -7.9) - 6.7 (-3.5 to 9.8) Lower-sodium DASH vs higher-sodium control: -15 High (3.5 g)Intermediate (2.3 g)Low (1.2 g) Dietary Sodium 0

3. 135 130 125 120 115 0 140 145 ©2011 MFMER | slide-3 Typical diet, High sodium DASH diet, low sodium 55 - 76 48 - 54 42 - 4723 - 41 Age (yr) Mean SBP (mm Hg)

4. ©2011 MFMER | slide-4 Global burden of high blood pressure in 2001 Worldwide 54 % of stroke and 47 % of ischemic heart disease were attributable to high blood pressure Half of this burden occurred in people with hypertension, the remainder in those with lesser degree of high BP About 80 % of attributable burden occurred in low and middle-income countries, over half in people aged 45-69 years old Lawes CMM et al, Lancet 2008;371:1513-18

5. .. Ischemic Heart Disease Mortality Has a Linear Relationship with Systolic and Diastolic Blood Pressure Lewington S et al, Lancet 2002;360:1903-1913........................ Age at risk: 80-89 years 70-79 years 60-69 years 50-59 years 40-49 years B: Diastolic blood pressure Age at risk: 80-89 years 70-79 years 60-69 years 50-59 years 40-49 years A: Sistolic blood pressure IHD Mortality Floating absolute risl and 95 % Cl IHD Mortality Floating absolute risl and 95 % Cl 1 2 4 8 16 32 64 128 256 1 2 4 8 16 32 64 128 256 70809010011020406080 Usual systolic blood pressure (mm Hg) Usual diastolic blood pressure (mm Hg)

6. Stroke Mortality Has a Linear Relationship with Systolic and Diastolic Blood Pressure In Each Decade Lewington S et al, Lancet 2002;360:1903-1913 Age at risk: 80-89 years 70-79 years 60-69 years 50-59 years A: Sistolic blood pressure IHD Mortality Floating absolute risl and 95 % Cl 1 2 4 8 16 32 64 128 256 Age at risk: 80-89 years 70-79 years 60-69 years 50-59 years IHD Mortality Floating absolute risl and 95 % Cl 1 2 4 8 16 32 64 128 256 708090100110120140160180 Usual systolic blood pressure (mm Hg) Usual diastolic blood pressure (mm Hg) B: Diastolic blood pressure

7. ©2011 MFMER | slide-7 Risk of hypertension (%) *Residual lifetime risk of developing hypertension among people with blood pressure <140/90 mmHg Years MenWomen Source: Vasan RS, et al. JAMA 2002; 287:1003-1010 Framingham Heart Study High Blood Pressure: Lifetime Risk* Starting at Age 55-65 Years

8. ©2011 MFMER | slide-8 Changes in BP Classification Hypertension 2003;289:2560-2572.

9. ©2011 MFMER | slide-9 Ambulatory BP Monitoring >Home BP Monitoring > Clinic BP Measurement Correlation with CV Outcomes and End Organ Damage CV Outcomes and End Organ Damage Ambulatory BP Monitoring Home BP Monitoring Clinic BP Measurement Ohkubo T et al, J Hypertens 2000;18:847-854 Staessen JA et al, JAMA 1999;282:539-542

10. ©2011 MFMER | slide-10 Compared to Ambulatory BP 135/85 Sensitivity Mean (95% CI) Specificity Mean (95% CI) Clinic BP 140/90 74.6 % (60.7-84.8) 74.6 % (47.9-90.4) Home BP 135/85 85.7 % (78-91) 62.4 % (48-75) Clinic BP and Home BP Accuracy Compared To Ambulatory BP: Systematic Review Hodgkinson J et al, BMJ 2011;342:d3621

11. ©2011 MFMER | slide-11 Probability (%) that Home or Clinic BP is Correct, Compared to Ambulatory BP Prevalence Positive Home Clinic Negative Home Clinic 10 % 19 25 97 96 30 % 47 56 90 87 50 % 67 75 80 75 Hodgkinson J et al, BMJ 2011;342:d3621

12. ©2011 MFMER | slide-12 Antihypertensive therapy on patients with CVD without HTN: Meta-analysis OutcomeRRRARR (events/1000) Stroke23 %-8 MI20 %-13 CHF29 %-44 Composite15 %-27 CVD deaths17 %-15 Total deaths13 %-14 Thompson A M et al, JAMA 2011;305:913

13. ©2011 MFMER | slide-13 The Linear Relationship and Normal Distribution of Risk Factor and Events Paradox Georgiopoulou V V et al. Circ Heart Fail 2011;4:528-533 15% 10% 0% 5% 4.8 % 6.4 % 11.6% 13.6% <120 120-139 140-159160 10-year HF Incidence Systolic BP has a direct relationship with HF risk 0 10 30 20 <120 120-139 140-159160 40 17 38 37 15 Heart Failure Events Approx. half the incident cases of HF occurred in those with systolic BP < 140 mmHg

14. ©2011 MFMER | slide-14 11,506 high-risk hypertensive patients randomized to benazepril (40 mg) and amlodipine (10 mg) or benazepril (40 mg) and HCTZ (25 mg) for 36 months* Jamerson K et al. NEJM 2008;359:2417-28. Benazepril/HCTZ Benazepril/Amlodipine Composite of CV death, MI, stroke, hospitalization for angina, sudden cardiac arrest, and coronary revascularization (%) Time to first cardiovascular event (days) 20% RRR, HR=0.80, P=0.0002 0.16 0.14 0.12 0.10 0.08 0.06 0.04 0.02 0.00 0 200 400 600 800 1000 1200 1400 *The study was prematurely stopped Is the combination benazepril + amlodipine better than benazepril + HCTZ to prevent CVD? ACCOMPLISH Trial

15. ©2011 MFMER | slide-15 The advantage of benazepril/amlodipine vs. benazepril/hctz was driven by non-fatal MI and coronary revascularization HOPE Trials components of the composite endpoint showed uniform statistical benefit on clinically relevant outcomes

16. ©2011 MFMER | slide-16 115 120 125 130 135 140 145 150 155 160 0.5 x 0.8 x 0.68 x 0.5= 0.13 La estrategia de tratar al grupo de alto riesgo concentra la Intervención y limita el beneficio Población con hipertensión arterial bajo control (50 %) Población en tratamiento antihipertensivo con medicamentos (68 %) Población consciente de tener hipertensión arterial (80 %) Población elegible de tratamiento anti- hipertensivo con medicamentos

17. ©2011 MFMER | slide-17 Source: Ford, E. S. et al. Figure 2b, Circulation 2009;120:1181-1188. Reprinted with permission. Blood pressure age-adjusted percentage Change in Blood Pressure Levels in the United States Over Time:NHANES

18. ©2011 MFMER | slide-18 El efecto en eventos coronarios y ataque cerebral de la reducción de presión arterial sistólica en relación a la edad y el grado en la reducción de la presión arterial (dependiente de la intensidad de tratamiento) Law M R et al. BMJ 2009;338:bmj.b1665 24% CI AC 1 No. Meds. 3 48% 33% 60% Reducción de riesgo relativo

19. ©2011 MFMER | slide-19 Law M R et al. BMJ 2009;338:bmj.b1665 24% CI AC 1 No. Meds. 3 33% 45% 62% El efecto en eventos coronarios y ataque cerebral de la reducción de presión arterial diastólica en relación a la edad y el grado en la reducción de la presión arterial (dependiente de la intensidad de tratamiento) Reducción de riesgo relativo

20. Extent of awareness, treatment and control of high blood pressure by age (NHANES: 2005–2008). Roger V L et al. Circulation 2011;123:e18-e209

21. ©2011 MFMER | slide-21 Title Here Type your first bulleted point here Type your second bulleted point here First subpoint Second subpoint Type your third bulleted point here Etc, etc, etc… Type the footnote/source in this space

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23. ©2011 MFMER | slide-23 Title for Chart Subtitle for Chart Type the footnote/source in this space % East West North

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25. ©2011 MFMER | slide-25 Title for Chart Subtitle for Chart Type the footnote/source in this space % East West North

26. ©2011 MFMER | slide-26 Title for Chart Subtitle for Chart Type the footnote/source in this space % East West North Years

27. ©2011 MFMER | slide-27 Title for Table Subtitle for Table Type the footnote/source in this space Column 1Column 2Column 3Column 4Column 5 Row 1Red 12.347%P<0.001 Row 2Yellow 459.226%P=0.05 Row 3Green 56.798%NS Row 4Blue 1.0 2%P>0.01 Row 5Pink 56.914%P<0.0001 Row 6Violet 25.435%P=0.01 Row 7Orange1,256.2 5%P<0.001

28. ©2011 MFMER | slide-28 Title for Organizational Chart Subtitle for Organization Chart Box 1 Box 2 Box 6 Box 3 Box 7 Box 4 Box 8 Box 5 Box 9 Type the footnote/source in this space

29. ©2011 MFMER | slide-29 Mayo Clinic Locations

30. ©2011 MFMER | slide-30 4,733 diabetic patients randomized to intensive BP control (target SBP <120 mm Hg) or standard BP control (target SBP <140 mm Hg) for 4.7 years Total stroke HR=0.88 95% CI (0.73-1.06) HR=0.59 95% CI (0.39-0.89) Nonfatal MI, nonfatal stroke, or CV death ACCORD Study Group. NEJM 2010;362:1575-85. Intensive vs. Standard Blood Pressure Control in Diabetics: ACCORD Trial Intensive BP control in DM does not reduce a composite of adverse CV events, but does reduce the rate of stroke Patients with Events (%) 20 15 10 5 0 20 15 10 5 0 4 32 1 0 56 7 8 4 32 1 0 56 7 8 Years Post-Randomization

31. ©2011 MFMER | slide-31 4,733 diabetic patients randomized to intensive BP control (target SBP <120 mm Hg) or standard BP control (target SBP <140 mm Hg) for 4.7 years Intensive BP control in DM does not reduce a composite of adverse CV events, but does reduce the rate of stroke Total stroke HR=0.88 95% CI (0.73-1.06) HR=0.59 95% CI (0.39-0.89) Nonfatal MI, nonfatal stroke, or CV death ACCORD Study Group. NEJM 2010;362:1575-85. Intensive vs. Standard Blood Pressure Control in Diabetics: ACCORD Trial

32. ©2011 MFMER | slide-32 Sipahi, I. et al. J Am Coll Cardiol 2006;48:833-838 CAMELOT-IVUS Substudy (n=274) RCT, Comparison of Amlodipine vs. Enalapril vs. Placebo In CHD patients with DBP<100 mmHg Systolic Blood Pressure on Treatment Was Related to Progression of Coronary Plaque Change in atheroma volume (mm 3 ) JNC 7 Categories 30 20 15 -10 -20 10 0 Normal -15 -5 5 25 PrehypertensionHypertension p<0.001 p<0.001 by ANCOVA p=0.01 P=0.039 40 30 20 -10 -20 10 0 -30 100 120 140 160 180 SBP (mm Hg) Change in atheroma volume (mm 3 )

33. ©2011 MFMER | slide-33 Sipahi, I. et al. J Am Coll Cardiol 2006;48:833-838 CAMELOT-IVUS Substudy (n=274) RCT, Comparison of Amlodipine vs. Enalapril vs. Placebo In CHD patients with DBP<100 mmHg Systolic Blood Pressure on Treatment Was Related to Progression of Coronary Plaque 40 30 20 -10 -20 10 0 -30 100 120 140 160 180 SBP (mm Hg) Change in atheroma volume (mm 3 )

34. ©2011 MFMER | slide-34 Sipahi, I. et al. J Am Coll Cardiol 2006;48:833-838 CAMELOT-IVUS Substudy (n=274) RCT, Comparison of Amlodipine vs. Enalapril vs. Placebo In CHD patients with DBP<100 mmHg Systolic Blood Pressure on Treatment Was Related to Progression of Coronary Plaque Change in atheroma volume (mm 3 ) JNC 7 Categories 30 20 15 -10 -20 10 0 Normal -15 -5 5 25 PrehypertensionHypertension p<0.001 p<0.001 by ANCOVA p=0.01 P=0.039

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