1. 1 Current & New treatment strategies to address CV Risk

2. 0204060 Age (yrs) Evolution of Atherosclerosis Clinical Events GeneticEnvironmental

3. Atherosclerosis: ‘Investing in your Arteries ’ Early Intervention for Lifetime Risk management

4. Framingham Heart Study:Lifetime Ri sk Adjusted Cumulative Incidence 50% 39% 27 % Attained Age 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 50 60 70 80 90 69% 50% 46% 36% 5% 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 50 60 70 80 90 8% ≥2 Major RFs 1 Major RF ≥ Elevated RF ≥ Not Elevated RF All Optimal RFs Men Women Lloyd-Jones Circ. 2006; 113: 791-798

5. Age and CV Risk in Diabetes Booth Lancet 2006; 368: 29-36 30 25 20 15 10 30 25 20 15 10 5 0 20-3031-4041-4546-5051-6056-6061-6566-7071-7576-8081-85 Women Women with diabetes Women without diabetes Age (years) 5 0 20-3031-4041-4546-5051-6056-6061-6566-7071-7576-8081-85 Men Men with diabetes Men without diabetes Age (years)

6. Current Guidelines Based on Short term Absolute Risk

7. Individuals with low 10-year but high lifetime risk have a greater subclinical disease burden and greater incidence of atherosclerotic progression compared with individuals with low 10-year and low lifetime risk, even at younger ages New Guidelines

8. Not at Goal BP (<140/90 mm Hg) (<130/80 mm Hg for those with diabetes or chronic kidney disease) Initial Drug Choices Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed With Compelling Indications Lifestyle Modifications Stage 2 Hypertension (SBP  160 or DBP  100 mm Hg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 Hypertension (SBP 140-159 or DBP 90-99 mm Hg) Thiazide-type diuretics for most May consider ACEI, ARB, BB, CCB, or combination Without Compelling Indications JNC 7 Algorithm for Treatment of Hypertension Chobanian et al. JAMA. 2003;289:2560-2572.

9. ESH  ESC and JNC 7 Guidelines Recommend Target BP Goals of <140/90 mmHg for Uncomplicated Hypertension and <130/80 mmHg for Complicated Hypertension 1 Type of hypertensionBP goal (mmHg) Uncomplicated<140/90 Complicated Diabetes mellitus<130/80 Kidney disease<130/80* Other high risk (stroke, myocardial infarction) <130/80 1. Task Force of ESH–ESC. J Hypertens 2007;25:1105  87 2. Chobanian et al. Hypertension 2003;42:1206–52 *Lower if proteinuria is >1 g/day

10. Blood Pressure Targets UncomplicatedDMCRF US (2003 )< 140/90 < 130/80 < 130/80 Europe (2007)< 140/90 < 130/80 < 130/80 WHO/ISH (2004)SBP < 140 < 130/80 < 130/80 UK (2004)< 140/85 < 130/80 < 130/80 China (2005)< 140/90 < 130/80 < 130/80