Cleo De Merode

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Cleo De Merode
Cleo De Merode
Boldini, 1901
Boldini 1901
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HYPERTENSION
beyond The Number
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.it so affects the minute and capillary circulat
ion, as to render greater action necessary to
force the blood through the distant
sub-divisions of the vascular system.
Richard Bright 1836
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CVD Leading Cause of Death for Men and Women
(United States, 2001)
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One in Four Americans Has CVD
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Burden of Atherosclerotic Vascular
Disease

• Prevalence64.4 millions
• Annual rate
• --Myocardial infarction-1.2 millions
• --Stroke-700,00
• --Cardiac catheterization-1.4 millions
• --Percutaneous revascularization-1.1millions
• --Surgical revasculariztion-571,000
• Cardiovascular mortality-931,000 one death
• every 34 seconds
• Annual Cost386 Billions

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CV Mortality Risk DoublesWith Each 20/10 mmHg
Increase in BP
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Reducing SBP Reduces CV Mortality
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Unacceptable BP Control Rates Require Increased
Awareness, More Aggressive Treatment
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JNC 7 New BP Classifications
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JNC 7 Recommended BP Goals
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There is no threshold number For
Hypertension As set in the Guideline Risk
start as BP exceed 115/75
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ASSESS GLOBAL RISK FACTORS
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The Anglo-Scandinavian Cardiac Outcomes Trial
(ASCOT) Study Design
Moderate-risk hypertensive patients

Randomized N 19,257
Amlodipine ? perindopril ? doxazosin GITs
Atenolol ? bendroflumethiazide ? doxazosin GITs

n 10,305 Randomized, Double Blind
Eligible for lipid lowering
Not eligible for lipid lowering

• Expected mean follow-up 5 years
• Primary end point nonfatal MI and fatal CHD .
  Stop at 3.3 years

n 5168 Atorvastatin 10 mg
n 5137 Placebo
Adapted from Sever PS et al, for the ASCOT
Investigators. J Hypertens. 2001191139-1147.
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ASCOT-LLA Baseline Characteristics in
Hypertensive Patients With Multiple Risk Factors
Sever PS et al, for the ASCOT Investigators.
Lancet. 20033611149-
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ASCOT-LLA Primary End Point Nonfatal MI and
Fatal CHD
Originally planned length of trial 5 years
Actual length of trial median 3.3 years
Atorvastatin10 mg (n 5168) Placebo (n 5137)
36relative riskreduction in nonfatal MI and
fatal CHD
Cumulative Incidence ()
(P.0005)
HR 0.64 (0.50-0.83)
5.0
Years
.
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ASCOT-LLA Reduction in Nonfatal MI
Originally planned length of trial 5 years
Actual length of trial median 3.3 years
3.0
Atorvastatin 10 mg (n 5168) Placebo (n 5137)
45 relative risk reductionin nonfatal MI (P
.0002)
2.0
Cumulative Incidence ()
1.0
0.0
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
5.0
Years
Data on file. Pfizer Inc, New York, NY.
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• You have to have
• a very good reason
• NOT to offer a hypertensive patient (with 3 other
  risks)
• Statin Therapy

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Different medicationDifferent Outcome
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Losartan Intervention For Endpoint Reduction Trial
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LIFE
New onset DM
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The Anglo-Scandinavian Cardiac Outcomes Trial
(ASCOT) Study Design
Moderate-risk hypertensive patients

Randomized N 19,257
Amlodipine ? perindopril ? doxazosin GITs
Atenolol ? bendroflumethiazide ? doxazosin GITs

-Systolic BP is slightly different
135.5(Amlodipine/Perindopril)
Versus 136.3(Atenolol/bendroflumethiazi
de) -14 All cause mortality -16
All Cardiovascular events and procedures -23
Stroke -24 Cardiovascular mortality
n 10,305 Randomized, Double Blind
Eligible for lipid lowering
Not eligible for lipid lowering

• Expected mean follow-up 5 years
• Primary end point nonfatal MI and fatal CHD .
  Stop at 3.3 years

n 5168 Atorvastatin 10 mg
n 5137 Placebo
Adapted from Sever PS et al, for the ASCOT
Investigators. J Hypertens. 2001191139-1147.
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Choices of Medication should be
Individualized NOT
Generalized
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The Art of Combination TherapyA Practical
Strategy
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The Art of Combination TherapyESH/ESC Guidelines
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THANK YOU