Presenter Dr. Ihab Suliman Sponsor ASTRA-ZENECA

Confirmed by genetic analysis showing a mutation in exon 7 of the TGFBR2 gene.

Patients with this autosomal dominant syndrome are at high risk for aortic dissection or rupture at an early age

Treatment of HTN in elderly 83 years old male is seen in the clinic for

persistent High SBP OF 170-180 mmHg.

His SBP Should be treated to below?? 130 mmHg 140 mmHg 150 mmhg

What do guidelines say?

Guidelines Statement

JNC7 2003 No mention of over-80s, treated as other patients

BHS 2004 “For those aged over 80 at the time of diagnosis of hypertension, no clear guidance can be given”

NICE 2007 “offer patients over 80 years of age the same treatment as other patients over 55, taking account of any comorbidity and their existing burden of drug use, but patients over 80 years of age are poorly represented in clinical trials and the effectiveness of treatment in this group is less certain”

ESH/ESC 2007

“In subjects aged 80 years or over, evidence for antihypertensive treatment is as yet inconclusive”

Design of HYPVET

An 83-year-old woman with Heart Failure, was admitted to the Hospital for IV Diuresis .

What is Her Mortality at one Year ?

If She was a he what is the expected Mortality?

Jong et al. Arch Intern Med. 2002;162:1689-1694.

Age- and Sex-Stratified Case-Fatality Rates 30 Days and 1 Year After First Hospitalization for HF

Men Women

Mortality, % Mortality, %

Age Group, y No. of Patients 30-Day 1-Year No. of Patients 30-Day 1-Year

20-49

50-64

65-74

≥75

All Ages

655

3048

5923

9310

18,936

4.6

5.5

8.6

15.6

11.4

15.0

20.5

28.8

43.1

34.0

375

1892

4412

13,087

19,766

4.3

5.4

6.8

14.7

11.8

10.9

19.5

23.0

37.9

32.3

Pneumopericardium

The first successful surgical correction of an LV aneurysm occurred in 1957 by Dr. Bailey

Done without off cardiac bypass by placing a clamp on the base of an aneurysm and passing suture beneath allowing excision of the aneurysm.

NEJM 29TH MARCH 2009

Adding surgical ventricular reconstruction to CABG reduced the left ventricular volume, as compared with CABG alone. 

However, this anatomical change was not associated with a greater improvement in symptoms or exercise tolerance or with a reduction in the rate of death or hospitalization for cardiac causes.

ARBs were widely believed to be useful in Diastolic Heart Failure or prevent Recurrence of Atrial Fibrillation.

What are the two Studies which blow these two Facts

Months from Randomization

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f P

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ary

Eve

nts

(%

)40 -

0 -

10 -

20 -

30 -

0 6 12 18 24 36 4230 48 6054

2067 1929 1812 1730 1640 1513 12911569 1088 4978162061 1921 1808 1715 1618 1466 12461539 1051 446776

No. at Risk

IrbesartanPlacebo

HR (95% CI) = 0.95 (0.86-1.05)Log-rank p=0.35 Placebo

Irbesartan

NEJM16-4-2009

What is Heyde Syndrome ??

1958 by Dr Edward C. Heyde, an internist living and working in Vancouver, WA in a letter to the New England Journal of Medicine.

He reported ten patients with the association.

A letter appearing shortly after confirmed an odds ratio of almost 3.0 between the two diseases

Is a syndrome of aortic valve stenosis associated with gastrointestinal bleeding from colonic angiodysplasia. It is named after Dr. Edward C. Heyde, who first described the association in 1958.

• In the 45 years following its initial description, no plausible explanations could be found for the association between aortic valve stenosis and gastrointestinal bleeding.

• Indeed, the association itself was questioned by a number of researchers.

•  A number of reports stressed, however, that replacement of the diseased aortic valve often led to resolution of the coagulopathy.

Paul Ridker the author of the JUPITER trial used hs CRP > 2mg as criterion for inclusion the 17000 patient Study.

What JUPITER stand for ?

What other Biomarkers can be used ?

Justification for the Use of statins in Primary prevention: an

Intervention Trial Evaluating Rosuvastatin

Ridker P et al. N Eng J Med 2008;359: 2195-2207