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Caduet (Dr. Ismahun Maret 2009)
Caduet (Dr. Ismahun Maret 2009)
Changing
Blood pressure and Atheroma Lessons from veins Veins dont develop atheroma even in people
Pulmonary Hypertension associated with
atheroma of pulmonary venous system ; pressure) develop atheroma ;
Venous grafts into coronary circulation (high Pressure is permissive for the development of
atheroma ;
15
10 5 0 -5 -10 P = 0.039 -15 -20 Normal Prehypertension Hypertension P = 0.01
JNC 7 Categories
Majority of US Hypertensive Patients Not at SBP Goal of <140 mm Hg: Goal Gap
14.0
12.0 10.0
131140
0.0 8190
141150
151160
231240
121130
201210
191200
SBP Range (mm Hg) SBP = Systolic Blood Pressure Adapted from Whyte JL et al. J Clin Hypertens. 2001;3:211-216.
221230
241250
161170
171180
181190
101110
111120
211220
49.6%
16.1%
150
140
100
23.6%
50 0 50
90
100
NHANES = National Health and Nutrition Examination Survey; SBP = systolic blood pressure; DBP = diastolic blood pressure.
<60 years
Burden of Disease
25
20
Year
72 77 82 87 92
15
10
2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5 11.0
50
Distribution of serum cholesterol and coronary heart disease (CHD) deaths of men in Finland, aged 30 to 59 years (1972, 1977, and 1982 cohorts combined) and odds ratio of CHD mortality associated with serum cholesterol
5.5
5
4.5 4 3.5
40
30 3 2.5 20 2
1.5
10 1 0.5 0 5.0 5.0-6.49 6.5-7.99 >8.0 Serum Cholesterol level (Mmol/l)
Serum Cholesterol CHD deaths Odds ratio
18
1.00 0.50
9 4
12
0.25
3.6 139
3.8 147
4.0 155
4.2 162
4.4 170
What we define asnormalvalues for Blood Pressure and Cholesterol are based on usual values for our populationsthese are not normal values for a human being, they are the usual values of a human being at risk of dying prematurely from vascular disease
B. Williams, 2006
The Population Burden of Cardiovascular Disease is in those people with modest elevations of multiple risk factors, NOT those with single, extreme elevations of single risk factors.
B. Williams, 2006
Increased Number of CV Events (MI) in Patients with Hypertension Plus Other CV Risk Factors
512 256 Odds Ratio (99% CI) 128 64 32 16 8 4 2 1 Risk Factors Smoking Diabetes HTN (1) (2) (3) Risk Ratio
2.9 (2.6-3.2) 2.4 (2.1-2.7) 1.9 (1.7-2.1)
HTN + 3 Risk Factors >20-Fold Increase OR from 1.9 (HTN only) to 42.3
HTN
Lipids (4)
3.3 (2.8-3.8)
1+2+3
13.0 (10.7-15.8)
All 4
42.3 (33.2-54.0)
+ Obes
+ PS
All RFs
MI=myocardial infarction; PS=psychosocial. Reproduced with permission from Yusuf S et al. Lancet. 2004;364:937-952. Please see prescribing information at the end of this slide presentation.
20 15
10
170
180
5
0
3%
Reference
+ Male + Diabetes
+ 60 years
Risk factors include: treated diabetes mellitus, diabetic nephropathy, asymptomatic carotid stenosis 70%, Systolic blood pressure [SBP], 150 mm Hg, treated hypercholesterolaemia, current smoking, men 55 y, women 70 y.
Bhatt DL et al. JAMA. 2006;295:180-189.
NHANES :Prevalence of
73.7
81.8 71.4
84.0
65.9 83.4
61.2a
42.2b 48.8
b. `Rate based on treatment goal <130/80 mm Hg = 23.2% HTN=hypertension Wong ND et al. Arch Intern Med 2007; 167: 2431-2436. CKD=chronic kidney disease
do not have very high BP or Cholesterol values but their values are not normal, either !
Potential Benefit of Blood Pressure and Cholesterol Lowering on Death (per 10,000 Patient-Years)
34
21 12
23
Cholesterol Lowering
18 17
13 12 6
245+
10 6
8 9 6 6 4 3
<182
11 8 8 6 5
14
Class
C.V.D.
Normal
None
None
None
Hypertension
Stage 1 Stage 2 Occasional / Intermittent > 120/80 Sustained > 140/90 Marked & Sustained >140/90 & >160/90
Early
Progre ssive Advan ced
Several
None
Early signs present
Many
Stage 3
Many
Overtly Overtly present present with with or without progression CVD events
JNC 7
2003
(SBP 140159 or DBP 9099 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.
(SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB)
Step 1
Step 2
Step 3 Step 4 Resistant Hypertension
A : ACE inhibitor or Angiotensin Receptor Blocker B : Betablocker
A ( or B ) + C or D
2004 PPS
2004 PPS
Risk Category CHD and CHD risk equivalents (10-year risk >20%)
*Almost all people with 01 risk factor have a 10-year risk <10%; thus, Framingham risk calculations are not necessary.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
2007 guidelines on hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) OD: subclinical organ damage, MS: metabolic syndrome.
Nondiabetic Men
CVD risk <10% over next 10 year CVD risk 10-20% over next 10 y. CVD risk >20% over next 10 year
Age 50 59 years
180 160 SBP 140 120 100
CVD risk over next 10 years 30% 10% 20% SBP = Systolic blood Pressure TC : HDL = Total Cholesterol to HDL Cholesterol ratio
3 4 5 6 7 8 9 10 TC : HDL
Nondiabetic Women
CVD risk <10% over next 10 year CVD risk 10-20% over next 10 y. CVD risk >20% over next 10 year
Age 50 59 years
180 160 SBP 140 120 100
3 4 5 6 7 8 9 10 TC : HDL
CVD risk over next 10 years 30% 10% 20% SBP = Systolic blood Pressure TC : HDL = Total Cholesterol to HDL Cholesterol ratio
3 4 5 6 7 8 9 10 TC : HDL
Nondiabetic Men
Primary Prevention:
Secondary Prevention:
Any Vascular disease or Target organ damage or Diabetes Treat stage 1 hypertension (> 140/90 mmHg) Prescribe statin ( irrespective of baseline total Cholesterol ) Target total Cholesterol <4,0 mmol/l or 25% reduction Prescribe Aspirin 75 mg od Do not prescribe vitamin waste of money.
Most Hypertensive Patients are at sufficient CVD risk to benefit from a statin, irrespective of their baseline cholesterol level
Optimising Hypertension Management by Addition of Statin Therapy May Reduce CV Events by Half
Williams B. J Am Coll Cardiol. 2005;45:813-827. Reproduced with permission from Professor Bryan Williams.
5%
0% 2000
B. Williams, 2006
2001
2002
2003
2004
2005
50%
40% 30%
20%
10% 0% 2000
B. Williams, 2006
2001
2002
2003
2004
2005
B. Williams, 2006
Conclusion
CVD risk assessment should be simple; The benefits of treatment are very large