Curiosare tra le raccomandazioni delle nuove linee guida ... linee guida sull’ipertensione arteriosa

  • View
    212

  • Download
    0

Embed Size (px)

Text of Curiosare tra le raccomandazioni delle nuove linee guida ... linee guida...

Curiosare tra le raccomandazioni delle nuove

linee guida sullipertensione arteriosa

Stefano Taddei Dipartimento di Medicina Clinica e Sperimentale

Universit di Pisa

2013 ESH/ESC Hypertension Guidelines

2003 Guidelines

2007 Guidelines

2009 Reappraisal ESH

2013 Guidelines

J Hypertens 2013;31:1281-1357

Eur Heart J 2013 June 14

Blood Pressure 2013 June 15

Historical Perspective

Table of contents

2013 ESH/ESC Hypertension Guidelines

1. Introduction

2. Epidemiological aspects

3. Diagnostic evaluation

4. Treatment approach

5. Treatment strategies

6. Treatment strategies in special conditions

7. Treatment of associated risk factors

8. Follow-up

9. Improvement of blood pressure control in hypertension

10. Hypertension disease management

11. Gaps in evidence and need for future trials

Appendix 1

Appendix 2

Acknowledgements

References

Table of contents

2013 ESH/ESC Hypertension Guidelines

1. Introduction

2. Epidemiological aspects

3. Diagnostic evaluation

4. Treatment approach

5. Treatment strategies

6. Treatment strategies in special conditions

7. Treatment of associated risk factors

8. Follow-up

9. Improvement of blood pressure control in hypertension

10. Hypertension disease management

11. Gaps in evidence and need for future trials

Appendix 1

Appendix 2

Acknowledgements

References

2007 ESH/ESC Hypertension Guidelines

Threshold BP

Target BP

General hypertensive

population

140/90 mmHg

< 140/90 mmHg

High / very high CV risk

(DM / CVD / CKD)

130/80 mmHg

< 130/80 mmHg

BP threshold / targets flexible according to CV risk level

142

137

149

138

150

146

140

130

148

130

100

110

120

130

140

150

160

Achieved SBP in Uncomplicated HypertensionS

BP

(m

mH

g)

OS HDFP AUS MRC FEV

BP Benefit

Zanchetti, Grassi, Mancia J Hypert 2009; 27: 923 - Mancia et al., J Hypert 2009; 27: 2121

%

130

110

100

120

140

150

160

Achieved SBP in Trials

Zanchetti, Grassi, Mancia, J Hypertens 2009; 27: 923-934, Mancia et al., J Hypertens 2009; 27: 2121

133

119

141

143

140

128132

134134

153

139

144145145

110

120

130

140

150

160

170

Diabetes

HOT

SHEP

UKPDS S. Eur ADV ABCD

RENHOPEAM

IDNT

ACRD

NAV

preDM

Benefit No benefit

SB

P (

mm

Hg

)

Active treatment

PROG

HT NT

IDNT

Achieved SBP in Trials

Zanchetti, Grassi, Mancia, J Hypertens 2009; 27: 923-934, Mancia et al., J Hypertens 2009; 27: 2121

133

119

141

143

140

128132

134134

153

139

144145145

110

120

130

140

150

160

170

129

124

130

122

136

124

128

135136

150

132

143

100

110

120

130

140

150

160

Diabetes Previous CVD

PATS

PROG

ACC

PROF

HOPE

EU

CAM-AM PREV

ACT

CAM-EN

PEATR

Stroke CHD

HOT

SHEP

UKPDS S. Eur ADV ABCD

RENHOPEAM

IDNT

SB

P (

mm

Hg

)ACRD

NAV

preDM

Benefit No benefit

SB

P (

mm

Hg

)

Benefit No benefit Benefit No benefit

Active treatment

Active treatment

PROG

HT NT

IDNT

Target SBP < 130 mmHg at high / very high CV risk

2013 ESH/ESC Hypertension Guidelines

No clear / consistent evidence of CV event reduction also by subgroup / post-hoc data analysis

No beneficial effects on risk of ESRD in nephropathic patients

Although mainly based on post-hoc approach, suspicion of a possible J curve phenomenon

Blood pressure goals in hypertension

2013 ESH/ESC Hypertension Guidelines2013 ESH/ESC Hypertension Guidelines

A SBP < 140 mmHg recommended/considered, regardless the level ofrisk

Low/moderate risk (IB)

Diabetes (IA)

Diabetic/nondiabetic CKD (IIaB)

Patients with CHD/previous stroke or TIA (IIaB)

A DBP < 90 mmHg recommended

Elderly patients

(> 65 - < 80 Years)

Elderly patients

(> 65 - < 80 Years)

Per quali livelli di pressione arteriosa

raccomandato iniziare il trattamento?

Recruitment BP criteria Mean BP at randomization

Trial SBP

(mmHg)

DBP

(mmHg)

SBP

(mmHg)

DBP

(mmHg)

EWPHE 160-239 or 90-119 183 101

Coope/warrende

r

>170 or >105 196 99

SHEP >160 and 180 or >105 195 94

MRC-elerly 160-209 and

2013 ESH/ESC Hypertension Guidelines

Elderly patients with SBP < 160 mmHg represent a

relevant number in trials showing beneficial effects of

antihypertensive drug treatment

Elderly hypertensive patients

2013 ESH/ESC Hypertension Guidelines

In ELDERLY HYPERTENSIVE PATIENTS drug treatment

is recommended when SBP 160 mmHg

may be considered (in those aged < 80 years) if SBP 140-159 mmHg, provided treatment is well tolerated

Evidence

Class Level

I A

IIb C

Elderly patients

(> 65 - < 80 Years)

Quali livelli di pressione arteriosa

raccomandato raggiungere con il

trattamento?

Achieved SBP in Trials

18559a M Zanchetti, Grassi, Mancia, J Hypertens 2009; 27: 923-934, Mancia et al., J Hypertens 2009; 27: 2121

138

145144

151151

156

167

143

162

150

120

130

140

150

160

170

180

190

ElderlyS

BP

(m

mH

g)

EW SHEP MRC S. China SCOPE

CW STOP S. Eur HYVET

JATOS

Benefit No benefit

Active treatment

Incidence of Morbidity / Mortality in HYVETN

o.

of

eve

nts

pe

r 1

00

pa

tie

nts

Total mortality

Fatal stroke

Heart failure

All stroke

0 1 2 3 4

Follow-up (yr)

0 1 2 3 4

Follow-up (yr)

0

1

2

3

4

5

6

7

8

0

1

2

3

4

5

0

10

20

30

1

2

3

4

5

6

7

Placebo

173/91 160/84 (mmHg)Active treatment

173/91 144/78 (mmHg)

-30%-39%

-21%-64%p < 0.0001 p = 0.019

p = 0.055 p = 0.046

Goal SBP < 150 mmHg

HYVET - Beckett, NEJM 2008; 358: 10

Target BP in the elderly

2013 ESH/ESC Hypertension Guidelines

In elderly pts (>65 ys of age) there is solid evidence to recommend reducing SBP to 150-140 mmHg (IA)

This is the case also in individuals older than 80 ys, provided they are in good physical/mental conditions

Any evidence in favour of lower BP targets?

BP targets in the elderly

2013 ESH/ESC Hypertension Guidelines

In fit elderly pts

Choice of antihypertensive drugs -

Conclusions from 2013 (and 2003 and 2007) Guidelines

2013 ESH/ESC Hypertension Guidelines

The main benefits of antihypertensive treatment are due to lowering BP per se and are largely independent of the drug employed

Although meta-analyses occasionally claim superiority of one class for some outcomes this largely depends on selection bias of trials. The largest meta-analyses

do not show clinically relevant between-class differences

Choice of antihypertensive drugs -

Conclusions from 2013 (and 2003 and 2007) Guidelines

2013 ESH/ESC Hypertension Guidelines

The main benefits of antihypertensive treatment are due to lowering BP per se and are largely independent of the drug employed

Although meta-analyses occasionally claim superiority of one class for some outcomes this largely depends on selection bias of trials. The largest meta-analyses

do not show clinically relevant between-class differences

Current Guidelines reconfirm that the following drugs classes are all suitable for initiation and maintenance of antihypertensive treatment either as monotherapy or

in some combinations with each other (IA)

Diuretics (thiazides / chlorthalidone / indapamide) Beta-blockers Calcium antagonists ACE-inhibitors Angiotensin receptor blockers

Algoritmo BHS/NICE (UK)

NICE/BHS, www.bhsoc.org 2006

Van Vark C et al, Eur Heart 2011

Effect of ACE-I and ARBs on total mortality

(158.998 patients)

Van Vark C et al, Eur Heart 2011

Effect of ACE-I and ARBs on total mortality

(