Quelle place de l’HTA dans le

risque résiduel ?

Dr Y Cottin
Dijon
 Liens d’intérêt

• Novartis, Boehringer-Ingelheim, Bayer, BMS, Pfizer

• Astra-Zeneca, Servier, Vifor, Servier, Sanofi
 Global, regional, and national comparative risk assessment of 79 behavioural,
environmental and occupational, and metabolic risks or clusters of risks, 1990–
2015: a systematic analysis for the Global Burden of Disease Study 2015

Lancet 2016;388:1659-1724
Heart Disease and Stroke Statistics-2023 Update: A Report From
the American Heart Association
Prevalence of IHD by age and sex

Tasa CW, et al. Circulation. 2023;147:e93-e621.

Heart Disease and Stroke Statistics-2023 Update: A Report From
the American Heart Association
Age-standardized global prevalence rates of IHD per 100 000, both sexes, 2020

6028 to 6922/100 000

Tasa CW, et al. Circulation. 2023;147:e93-e621.

Heart Disease and Stroke Statistics-2023 Update: A Report From
the American Heart Association
Age-standardized global mortality rates of IHD per 100 000, both sexes, 2020

252 to 370/100 000

Tasa CW, et al. Circulation. 2023;147:e93-e621.

Heart Disease and Stroke Statistics-2023 Update: A Report From
the American Heart Association

Tasa CW, et al. Circulation. 2023;147:e93-e621.

Heart Disease and Stroke Statistics-2023 Update: A Report From
the American Heart Association
Age-standardized global prevalence rates of ischemic stroke per 100 000, both sexes, 2020.

826 to 983/100 000

Tasa CW, et al. Circulation. 2023;147:e93-e621.

Heart Disease and Stroke Statistics-2023 Update: A Report From
the American Heart Association
Age-standardized global prevalence rates of ICH per 100 000, both sexes, 2020.

175 to 219/100 000

Tasa CW, et al. Circulation. 2023;147:e93-e621.

Heart Disease and Stroke Statistics-2023 Update: A Report From
the American Heart Association
Age-standardized global mortality rates of total stroke (all subtypes) per 100 000, both sexes,
2020.

98 to 125/100 000

Tasa CW, et al. Circulation. 2023;147:e93-e621.

Heart Disease and Stroke Statistics-2023 Update: A Report From
the American Heart Association
PAF of major risk factors for AF in the ARIC study, 1987 to 2007

Tasa CW, et al. Circulation. 2023;147:e93-e621.

 Global, regional, and national burden of stroke and its risk factors, 1990–2019: a
systematic analysis for the Global Burden of Disease Study 2019
ALL STROKES

ISCHEMIC STROKES

GBD 2019 Stroke Collaborators. Lancet Neurol 2021.20:795–820.

Global, regional, and national burden of stroke and its risk factors, 1990–2019: a
systematic analysis for the Global Burden of Disease Study 2019
Intracerebral Haemorrhage

Subarachnoid Haemorrhage

GBD 2019 Stroke Collaborators. Lancet Neurol 2021.20:795–820.

Global, regional, and national burden of stroke and its risk factors, 1990–2019: a
systematic analysis for the Global Burden of Disease Study 2019

GBD 2019 Stroke Collaborators. Lancet Neurol 2021.20:795–820.

 Hypertension Defined by 2017 ACC/AHA Guideline, Ideal Cardiovascular Health
Metrics, and Risk of Cardiovascular Disease: A Nationwide Prospective Cohort Study

Wu S, et al. Lancet Reg Health West. 2022;20:100350.

 Hypertension Defined by 2017 ACC/AHA Guideline, Ideal Cardiovascular Health
Metrics, and Risk of Cardiovascular Disease: A Nationwide Prospective Cohort Study

ICVHMs, ideal cardiovascular health metrics.

A/ Ideal smoking status was defined as never smoking or smoking cessation for more
than 12 months.
B/ Ideal physical activity was defined as ≥150 minutes/week moderate-intensity, ≥75
minute-s/week vigorous-intensity, or ≥150 minutes/week moderate- or vigorous-intensity
physical activities.
C/ Ideal diet was defined as fruit and vegetable intake ≥4¢5 cups/day.
D/ Ideal BMI was defined as a BMI level < 23 kg/m2,
E/ Ideal TC was defined as a TC level <200 mg/dL without treatment.
D/ Ideal FPG was defined as an FPG level <100 mg/dL without
treatment

The overall cardiovascular health status was grouped according to the number of ICVHMs
≤1, 2, 3, and ≥4 to allow for a reasonable number of participants in each
group

Wu S, et al. Lancet Reg Health West. 2022;20:100350.

 Hypertension Defined by 2017 ACC/AHA Guideline, Ideal Cardiovascular Health
Metrics, and Risk of Cardiovascular Disease: A Nationwide Prospective Cohort Study

MACE

Wu S, et al. Lancet Reg Health West. 2022;20:100350.

 Hypertension Defined by 2017 ACC/AHA Guideline, Ideal Cardiovascular Health
Metrics, and Risk of Cardiovascular Disease: A Nationwide Prospective Cohort Study

MACE

Wu S, et al. Lancet Reg Health West. 2022;20:100350.

 Age-stratified and blood-pressure-stratified effects of blood-pressure-
lowering pharmacotherapy for the prevention of cardiovascular disease
and death: an individual participant-level data meta-analysis
Rate of major cardiovascular events per 5 mm Hg reduction in systolic blood
pressure, stratified by treatment allocation and age categories at baseline

The Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2021;398:1053-1064.

 Age-stratified and blood-pressure-stratified effects of blood-pressure-
lowering pharmacotherapy for the prevention of cardiovascular disease
and death: an individual participant-level data meta-analysis

The Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2021;398:1053-1064.

Pharmacological blood pressure lowering for primary and secondary prevention of
cardiovascular disease across different levels of blood pressure: an individual
participant-level data meta-analysis

Rates of major cardiovascular events per 5 mm Hg reduction in systolic blood pressure, stratified
by treatment allocation and cardiovascular disease status at baseline
Major cardiovascular events were defined as a composition of fatal or non-fatal stroke, fatal or
non-fatal myocardial infarction or ischaemic heart disease, or heart failure causing death or
requiring admission to hospital.
The Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2021;397:1625-1636.
Pharmacological blood pressure lowering for primary and secondary prevention of
cardiovascular disease across different levels of blood pressure: an individual
participant-level data meta-analysis

The Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2021;397:1625-1636.

Time to Clinical Benefit of Intensive Blood Pressure Lowering in Patients 60 Years
and Older With Hypertension. A Secondary Analysis of Randomized Clinical Trials
Cumulative Incidence of Major Adverse Cardiovascular Events in the Standard and
Intensive Blood Pressure Treatment Groups

Chen T, et al. JAMA Intern Med. 2022;9:e2211657.

Association of Systolic Blood Pressure With Dementia Risk and the Role of Age, U-
Shaped Associations, and Mortality

Willem van Dalen J, et al. JAMA Intern Med. 2022;182:142-152.

 Post-SCA

Contrôle des Facteurs de risque Optimisation pharmacologique

Education Thérapeutique IEC/ARA II-Bétabloquants-Statine

FA Réduire le Risque Résiduel FE VG

Individualisation du risque

Anti-aggrégation Voie Inflammatoire

Lipides Diabétique
Anticoagulation CRP us

Prolongation : LDL-Cs :
- Ezetrol Agonistes : Canakinumab
- de Bithérapie anti-aggrégante - GLP-1 Colchicine
- PCSK9
- Ticagrelor ? Inhibiteurs :
Introduction AOD : Hpertrigycléridémie :
- Icosapent éthyle - SGLT-2
Rivaroxaban
Lp (a) :
-inhibiteur LP (a)
Differential occurrence, profile, and impact of first recurrent
cardiovascular events after an acute coronary syndrome
Among 46,694 patients with a median follow-up of 358 (25th, 75th percentiles 262,
486) days, a first ischemic event occurred in 4,307 patients (9.2%) as follows:
1/ MI in 5.8% (n = 2,690), 2/ stroke in 1.0% (n = 477), 3/ and CV-death in 2.4% (n =
1,140).

6%

2.4 %
1%

Hess CN, et al. Am Heart J. 2017;187:194-203

Cardiovascular risk in post-myocardial infarction patients:
nationwide real world data demonstrate the importance of
a long-term perspective

Jernberg T, et al. Eur Heart J. 2015;36:1163-70.

Differential occurrence, profile, and impact of first recurrent
cardiovascular events after an acute coronary syndrome
Among 46,694 patients with a median follow-up of 358 (25th, 75th percentiles 262,
486) days, a first ischemic event occurred in 4,307 patients (9.2%) as follows:
1/ MI in 5.8% (n = 2,690), 2/ stroke in 1.0% (n = 477), 3/ and CV-death in 2.4% (n =
1,140).

Hess CN, et al. Am Heart J. 2017;187:194-203

Differential occurrence, profile, and impact of first recurrent
cardiovascular events after an acute coronary syndrome

Hess CN, et al. Am Heart J. 2017;187:194-203

Biomarker-Based Risk Model to Predict Cardiovascular
Mortality in Patients With Stable Coronary Disease

Lindholm D, et al. J Am Coll Cardiol. 2017;70:813-826.

Biomarker-Based Risk Model to Predict Cardiovascular
Mortality in Patients With Stable Coronary Disease

Lindholm D, et al. J Am Coll Cardiol. 2017;70:813-826.

Biomarker-Based Risk Model to Predict Cardiovascular
Mortality in Patients With Stable Coronary Disease

Lindholm D, et al. J Am Coll Cardiol. 2017;70:813-826.

 Cardiovascular event rates and mortality according to
achieved systolic and diastolic blood pressure in patients with
stable coronary artery disease: an international cohort study
Data from 22 672 patients with stable coronary artery disease

Vidal-Petiot E, et al. Lancet. 2016;388:2142-2152.

 Cardiovascular event rates and mortality according to
achieved systolic and diastolic blood pressure in patients with
stable coronary artery disease: an international cohort study
Data from 22 672 patients with stable coronary artery disease

Vidal-Petiot E, et al. Lancet. 2016;388:2142-2152.

 Low coronary flow relative to myocardial mass predicts heart failure in
symptomatic hypertensive patients with no obstructive coronary artery disease

Brown JM, et al. Eur Heart J. 2021:ehab610.

Lone atrial fibrillation: does it exist?

Wyse DG, et al. J Am Coll Cardiol. 20146;63:1715-23.

Sex-Specific Considerations in the Presentation, Diagnosis, and
Management of Ischemic Heart Disease

•. 2022;79:1398-1406

Solola Nussbaum S, et al. J Am Coll Cardiol. 2022;79:1398-1406.

Sex-Based Differences in Heart Failure

Khan SS, et al. J Am Coll Cardiol. 2022;79:1530-1541.

Sex Differences in Cardiovascular Consequences of Hypertension,
Obesity, and Diabetes

Regensteiner JG, et al. J Am Coll Cardiol. 2022;79:1492-1505.

Obstructive Sleep Apnea
Outcomes in patients with acute myocardial infarction and know obstructive sleep
apnea: a nationwide analysis

Fauchier L, et al. In Press

Outcomes in patients with acute myocardial infarction and know obstructive sleep
apnea: a nationwide analysis

Fauchier L, et al. In Press

Outcomes in patients with acute myocardial infarction and know obstructive sleep
apnea: a nationwide analysis

Fauchier L, et al. In Press

Outcomes in patients with acute myocardial infarction and know obstructive sleep
apnea: a nationwide analysis

Fauchier L, et al. In Press

Association of obstructive sleep apnoea with cardiovascular events
in women and men with acute coronary syndrome

Wand X, et al. Eur Respir J. 2023;61:2201110.

Association of obstructive sleep apnoea with cardiovascular events
in women and men with acute coronary syndrome

Wand X, et al. Eur Respir J. 2023;61:2201110.

 ATELIER

Dr Y Cottin
Dijon
 Contexte clinique
• Patiente de 84 ans
• ATCD: cardiopathie dilatée non étiquetée, dyslipidémie,
hypothyroïdie, HTA, IRC stade 3A
• Traitement habituel: ENALAPRIL, BISOPROLOL,
FUROSEMIDE, ALDACTONE, LEVOTHYROX

• PEC à domicile par le SMUR pour détresse respiratoire

aigue avec douleur thoracique.
• Passage en FV: 1 CEE puis RACS.
 ETT

• VG modérément dilaté. HVG à prédominance apicale avec importantes

trabéculations apicales suspectes de non-compaction.
• FEVG très altérée estimée à 20% en autoFE. Hypokinésie globale avec
akinésie apicale, latéro-apicale, et de toute la paroi antérieure.
• Aorte ascendante de calibre normal. IA minime sans RA.
IM minime centrale. OG dilatée.
• DC limite à 3.3L/min non indexé.
• Cavités droites non dilatées, fonction systolique VD correcte (onde S'
9.5 cm/s). HTAP avec PAPS 35 + 15 mmHg.
• Franges graisseuse péricardiques.
VCi dilatée, peu compliante.
Coronarographie
Coronarographie
Quel est votre diagnostic ?
Prevalence, clinical features, and prognosis of acute myocardial
infarction attributable to coronary artery embolism

Shibata T, et al. Circulation 2015;132:241-50.

Coronary Embolus. An underappreciated cause of acute
coronary syndromes

Raphael CE, et al. JACC Cardiovasc Interv. 2018;11:172-180.

Quelles sont les causes d’embolies
coronaires ?
 Coronary embolism: A systematic review

%
25

20

15
22.4
10
17 16.5 15.1
5 8 8 7
3 3
0
EI FA s is
ally m
a
us m
a
ion ers
bo ic xo b to at th
n y m s c O
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lc ifi
th tr a t ro
e I a t r i
LV f ib ca
alv A
r y lic
o
r tv illa m
b
ea p E
H Pa

Lacey MJ, et al. Cardiovasc Revasc Med. 2019:S1553-8389(19)30311-2

 Quelle est la place de
l’hypertension dans les embolies
coronaires ?
Lone atrial fibrillation: does it exist?

Wyse DG, et al. J Am Coll Cardiol. 20146;63:1715-23.

Lone atrial fibrillation: does it exist?

Wyse DG, et al. J Am Coll Cardiol. 20146;63:1715-23.

Lone atrial fibrillation: does it exist?

Wyse DG, et al. J Am Coll Cardiol. 20146;63:1715-23.

Lone atrial fibrillation: does it exist?

Wyse DG, et al. J Am Coll Cardiol. 20146;63:1715-23.

How to use digital devices to detect and manage arrhythmias: an
EHRA practical guide

Svennberg E, et al. Europace 2022;24:979-1005.

 Methods
Classification in 6 groups population

Group 1: history of stroke Group 4: < 65 years

Group 2: > 75 years 4a- with and
Group 3: 65-74 years 4b- without comorbidities
3a- with and
3b- without comorbidities

Roger A, et al. Europace 2023;in press.

 Methods
• Longitudinal cohort study
• Population
• All patients admitted in French hospital (1546) in 2012
• Follow up during 5 years
• Last 2 years (2010-2012) medical history
• PMSI database, ICD-10

• Clinical outcomes
• Incidence of AF
• Incidences of ischaemic stroke, haemorrhagic stroke, major bleeding,
all-cause death and cardiovascular death during follow-up.

Group 1: history of stroke Group 4: < 65 years

Group 2: > 75 years
Group 3: 65-74 years
3a- with and
3b- without comorbidities
4a- with and
4b- without comorbidities
Roger A, et al. Europace 2023;in press.
Results
Prevalence of AF and yearly incidence of clinical outcomes in adult patients seen in French
hospitals in 2012

Roger A, et al. Europace 2023;in press.

 A nationwide study of Incident atrial fibrillation risk and atrial
fibrillation-related complications: implications for AF screening
strategies

Roger A, et al. Europace 2023;in press.

Results
Impact of the number of comorbidities on the annual incidence of AF in
groups 3 and 4

Roger A, et al. Europace 2023;in press.

• First algorithm evaluation in real-life

• Easy identification of high risk sub groups (arbitrarily cut off at

5%):
• > 75 years
• 65-74 years with at least 4 comorbidities
• < 65 years with at least 6 comorbidities

• Need further studies to evaluate systematic screening with digital tools

for this groups

• Which multimorbidity clusters could be more arrhythmogenic?

Roger A, et al. Europace 2023;in press.

Existe-il un risque d’embolies
multiples ?
 Evolution
• Passage en FA rapide mal tolérée sur le plan HD,
échec de réduction médicamenteuse.
• Evolution vers choc cardiogénique
• Mise sous DOBUTAMINE 10 ug/kg/min
• Cardioversion électrique: retour en RS après 1 CEE
150J sous AG.

• A J5: apparition d’une aphasie fluente type Wernicke,

sans déficit moteur
Scanner cérébral
Scanner cérébral
Scanner cardiaque
IRM cardiaque
•.
Acute myocardial infarction related to coronary artery embolism: A systematic
cardiac and cerebral magnetic resonance imaging study

Debeaumarche J, et al. Arch Cardiovasc Dis. 2022;115:457-466.

Coronary artery embolism and acute coronary syndrome: A critical
appraisal of existing data

Monin A, et al. Trends Cardiovasc Med. 2022:S1050-1738(22)00107-4.

 Contexte clinique
• Patiente de 71 ans
• ATCD: HAT, FA, maladie de Crohn
• Angor Instable.
Quel est votre diagnostic ?
Quelle stratégie thérapeutique ?
Quelle (s) Explorations ?
 Quelle (s) Causes de
Compression Coronaire ?
 External coronary artery compression (ECAC)

Clinical manifestations
Angina Myocardial infarction + MINOCA Ventricular arrythmia Sudden Cardiac Death None

Management

Echocardiography +/- Enlarged Pulmonary Artery

transoesophageal echocardiography
Myocardial Bridging
Magnetic Resonance Imaging
Aneurysm of the Left Sinus of Valsava
Computed tomography Angiography
Prosthetic Pulmonary Valve Placement
Angiography
Aortic Root Abcess

Metastatic Cardiac Tumor

Ventricular Pseudoaneurysm

Aortic Dissection

Parasitic Infections

Adapted Therapeutic Approach

Extrinsic compression of coronary and pulmonary vasculature

Batra K, et al. Cardiovasc Diagn Ther. 2021;11:1125-1139.

Left Main Coronary Artery Compression in Patients With Pulmonary
Arterial Hypertension and Angina

Galié N, et al. J Am Coll Cardiol. 2017;69:2008-2817.

Left Main Coronary Artery Compression in Patients With Pulmonary
Arterial Hypertension and Angina

Galié N, et al. J Am Coll Cardiol. 2017;69:2008-2817.