L

1
Liperteso anziano tra linee guida e buona
pratica clinica
Giancarlo ANTONUCCI SC Medicina Interna Ospedale
Galliera GENOVA
2
(No Transcript)
3
Changes in systolic and diastolic blood pressure
with age
Data from NHAES III, 19981991
4
(No Transcript)
5
(No Transcript)
6
(No Transcript)
7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
(No Transcript)
11
2 systematic review and meta-analysis

• Aortic PWV is a strong predictor of future CV
  events and all cause mortality
• Central haemodynamic indexes are independent
  predictors of future CV events and all-cause
  mortality.

Vlachopoulos C et al. JACC 201055(13)1318 Vlacho
poulos C et al. European Heart Journal (2010) 31,
1865
12
Lipertensione sistolica isolata è una
ipertensione secondaria ?
13
(No Transcript)
14
Associations of reduction in blood pressure with
riskreduction for total major cardiovascular
events
31 trials 190.606
Blood Pressure Lowering Treatment Trialists
Collaboration BMJ 20083361121
15
Does blood pressure reduction alone explain the
preventive effect of the drugs?
MR Law et Al. BMJ 2009338b1665
16
Box 7. Antihypertensive treatment in the elderly

1. Since the publication of the last guidelines,
   evidence from large meta-analyses of published
   trials confirms that in the elderly
   antihypertensive treatment is highly beneficial.
   The proportional benefit in patients aged more
   than 65 years is no less than that in younger
   patients.
2. Data from meta-analyses do not support the claim
   that antihypertensive drug classes significantly
   differ in their ability to lower BP and to exert
   cardiovascular protection, both in younger and in
   elderly patients. The choice of the drugs to
   employ should thus not be guided by age. Thiazide
   diuretics, ACE inhibitors, calcium antagonists,
   angiotensin receptor antagonists, and b-blockers
   can be considered for initiation and maintenance
   of treatment also in the elderly.

Reappraisal of ESH guidelines. Journal of
Hypertension 2009, Vol 27
17
Fino a quale età?

• 81 aa
• Vive solo
• Non fuma
• Non patologie rilevanti
• Creatinina 1,4 mg/dl ECG, glicemia, colesterolo
  normali
• PA 180-190 / 74-80 da almeno sei mesi

18
(No Transcript)
19
Treatment of hypertension in patients 80 years
and older The lower the better? A
meta-analysis of randomized controlled trials
Secondary endpoints
Bejan-Angoulvant T et al, J Hypertens. 2010
Jul28(7)1366
20
(No Transcript)
21
Box 7. Antihypertensive treatment in the elderly

• At variance from previous guidelines, evidence is
  now available from an outcome trial (HYVET) that
  antihypertensive treatment has benefits also in
  patients aged 80 years or more. BP-lowering drugs
  should thus be continued or initiated when
  patients turn 80, starting with monotherapy and
  adding a second drug if needed. Because HYVET
  patients were generally in good conditions, the
  extent to which HYVET data can be extrapolated to
  more fragile octogenarians is uncertain. The
  decision to treat should thus be taken on an
  individual basis, and patients should always be
  carefully monitored during and beyond the
  treatment titration phase.

Reappraisal of ESH guidelines. Journal of
Hypertension 2009, Vol 27
22
Fino a quali valori?

• 72 aa
• ex-fumatore
• Precedente SCA rivascolarizzato
  (PTCAstent) 4 aa fa
• Iperteso in terapia con 3 farmaci da almeno 30
  anni
• Creatinina 1,4
• PA 145-150/70 da almeno tre mesi

23
(No Transcript)
24
(No Transcript)
25
Box 7. Antihypertensive treatment in the elderly

• In the elderly, outcome trials have only
  addressed patients with an entry SBP at least
  160mmHg, and in no trial in which a benefit was
  shown achieved SBP averaged less than 140mmHg.
  Evidence from outcome trials addressing lower
  entry and achieving lower on-treatment values are
  thus needed, but common sense considerations
  suggest that also in the elderly drug treatment
  can be initiated when SBP is higher than
  140mmHg, and that SBP can be brought to below
  140mmHg, provided treatment is conducted with
  particular attention to adverse responses,
  potentially more frequent in the elderly.

Reappraisal of ESH guidelines. Journal of
Hypertension 2009, Vol 27
26
(No Transcript)
27
(No Transcript)
28
(No Transcript)
29
How stiffening of the aorta and elastic arteries
leads to compromised coronary flow
Possible link between large artery stiffness and
coronary flow velocity reserve. Saito M, et al.
Heart 200894e20
MF ORourke Heart 2008 94 690
30
(No Transcript)
31
Reappraisal of the European guidelines on
hypertension managementThe European Society of
Hypertension Task Force document

• The J-curve phenomenon is unlikely to occur below
  70-75, except perhaps in patients at high
  cardiovascular risk

130-139 / 80-85
J Hypertens. 2009
32
Ho un buon controllo nei diversi momenti della
giornata?

• 73 aa
• Da circa 1 anno in terapia con enalapril 20 mg e
  bisoprololo 2,5 mg la mattina
• Durante il giorno lamenta testa confusa
• PA nello studio 154/80
• Aggiunta idroclorotiazide 12,5 mg con
  peggioramento dei sintomi

33
HCTZ 12,5 mg Enalapril 20 Bisoprololo 2,5 mg
Valori medi 24h 116/57 fc 60 7-22 109/57
fc 64 22-7 131/56 fc 51
34
Prevalenza età-correlata dellipotensione
ortostatica
RIGIDITÀ ARTERIOSA ? sensibilità
barorecettoriale ? risposta SNS POLIPATOLOGIA PO
LITERAPIA
M.Parkinson 50 Diabete 20-25
2 sintomatica 16,2 asintomatica 23 ISH
ARIC (1)
CHS (2)

1. Rose KM et al. Am J Hypertens 2000 13571
2. Rutan GH et al. Hypertension 1992 19508

35
Orthostatic hypotension, mortality, and CV disease
American Journal of Hypertension, advance online
publication 2 September 2010
Atherosclerosis Risk in Communities (ARIC) study
Rotterdam study
Malmo Preventive Project
Honolulu Heart Program (HHP)
Five rural areas in Northern Finland
36
The value of ambulatory blood pressure in older
adults. The Dublin outcome study
Age and Ageing 2008 37 201
37
Morning surge in blood pressure as a predictor of
silent and clinical cerebrovascular disease in
elderly hypertensives a prospective study.
Kario et Al Circulation. 20031071401
38
(No Transcript)
39
(No Transcript)
40
Pro e Contro la somministrazione serale di
antipertensivi

Può migliorare il controllo notturno e del picco mattutino Assenza di forti evidenze sugli eventi CV
Possibile minor aderenza
Evidenza di riduzione della microalbuminaria Politerapia/ uso farmaci LA

Gianfranco Parati and Grzegorz Bilo. Journal of
Hypertension 2010, 281390
41
(No Transcript)
42
Ogni giorno è uguale ad un altro?

• 74 aa
• Ipertesa da almeno 15 aa in terapia con atenololo
  50 mg
• Precedente TIA 5 anni prima (ASA basse dosi)
• valori pressori molto variabili da visita a
  visita

43
(No Transcript)
44

• Prognostic significance of visit-to-visit
  variability, maximum systolic blood pressure, and
  episodic hypertension. Rothwell PM et all.
  Lancet 2010375895-905 
• Effects of beta blockers and calcium-channel
  blockers on within-individual variability in
  blood pressure and risk of stroke.
  Rothwell PM, et al
  ASCOT-BPLA and MRC Trial Investigators. Lancet
  Neurol 20109469-80 
• Effects of antihypertensive-drug class on
  interindividual variation in blood pressure and
  risk of stroke a systematic review and
  meta-analysisRothwell PM et al. Lancet
  2010375906-15 
• Limitations of the usual blood-pressure
  hypothesis and importance of variability,
  instability, and episodic hypertension. Rothwell
  PM. Lancet 2010375938-48

Dr Peter M Rothwell Neurologist (John Radcliffe
Hospital, Oxford, UK)
45
(No Transcript)
46
Analisi post-hoc di RCTs valore predittivo
indipendente della variabilità pressoria da
visita a visita (soggetti con pregresso TIA o
ictus)
Relative strength of association of mean versus
SD SBP with baseline SBP in the UK TIA trial
On the basis of measurements at seven
consecutive follow-up clinic visits.
Rothwell PM, Lancet 2010 375 895
47
(No Transcript)
48
The opposite effects of calcium-channel blockers
and ß blockers on variability
in ASCOT-BPLA
19.257 pt
x4
ASCOT-BPLA and MRC Trial Investigators. Lancet
Neurol 2010 9 469
49
(No Transcript)
50
(No Transcript)
51
Re-examining the efficacy of ?-blockers for the
treatment of hypertension a meta-analysis in
olders
17 stroke
N. Khan. CMAJ2006174(12)1737-42
DOI10.1503/cmaj.060110
52
Effects of antihypertensive-drug class on
interindividual variation in blood pressure and
risk of stroke a systematic review and
meta-analysis
398 trials
Rothwell PM. Lancet 2010375938-48
53
Maggior efficacia di CaA e D nel ridurre il
rischio di eventi CBV e la variabilità pressoria
da visita a visita
All large randomised trials of calcium-channel
blocking drugs versus ß blockers or ACE
inhibitors in which the mean and SD SBP during
follow-up were reported by treatment group
54
The Relationship Between Visit-to-Visit
Variability in Systolic Blood Pressure and
All-Cause Mortality in the General Population
Findings From NHANES III, 1988 to 1994

Paul Muntner et al. Hypertension 201157160
55
G.Mancia. Hypertension. 201157141
56
Espansione del concetto di variabilità
pressoria e nuova rilevanza

• A breve termine
• Effetto camice bianco
• A medio termine
• DS diurna (MPA)
• Dipping (MPA)/OH
• Surge (MPA)/OHT
• PA mattutina e serale (domiciliare)
• A lungo termine
• Da visita a visita (visit-to-visit)
• Domiciliare

Instabilità pressoria
57
Cervello vittima o colpevole?
Lesioni della sostanza bianca
58

• 74 aa
• Ipertesa da almeno 15 aa in terapia con atenololo
  50 mg
• Fumatrice di poche sigarette die
• Sedentaria, ansiosa
• Precedente TIA 5 anni prima (ASA basse dosi)
• I valori pressori sono molto variabili da visita
  a visita e risulta difficile il controllo
• sostituzione dellatenololo con Nifedipina GITS
  bassa-media dose

59
Conclusioni

• Dobbiamo prevenire un rischio cercando di non
  generare malattia
• In assenza di chiara EBM consideriamo sempre il
  singolo paziente
• Misuriamo meglio
• Importanza della qualità della vita