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Dr. A.Antonelli SIN GI

CONTROLLO OTTIMALE DELLA
PRESSIONE ARTERIOSA

Alessandro Antonelli
U.O Nefrologia
Ospedale Campo d...
Dr. A.Antonelli SIN GI

“ L’Ipertensione arteriosa è il

livello di pressione per il quale i
benefici (meno i rischi ed i ...
Dr. A.Antonelli SIN GI

Prevalenza ipertensione %

Prevalenza di ipertensione arteriosa
in rapporto ad età e razza negli U...
Dr. A.Antonelli SIN GI

Multiple Risk Factor Intervention Trial

Causes of death, RR

3,5

3,2

3
2,5

2,5

2

3,0

2,8
2,...
Dr. A.Antonelli SIN GI

Trials exploring the
optimal drug
Trials comparing more
intensive and less
intensive blood
pressur...
Dr. A.Antonelli SIN GI

Prospectively designed overviews of randomised trials
Trials comparing more intensive and less int...
Dr. A.Antonelli SIN GI

Trials exploring the
optimal drug
Trials comparing
active treatment and
placebo

Dr. A.Antonelli S...
Dr. A.Antonelli SIN GI

Prospectively designed overviews of randomised trials
ACE-inhibitor-based therapy vs placebo
Strok...
Dr. A.Antonelli SIN GI

Prospectively designed overviews of randomised trials
Calcium-antagonist-based therapy vs placebo
...
Dr. A.Antonelli SIN GI

Prospectively designed overviews of randomised trials

ACE-inhibitors vs
Calcium antagonists:
a co...
Dr. A.Antonelli SIN GI

Ruolo dell’ipertensione arteriosa nel
determinare il danno renale
Ipertensione arteriosa
(stadio I...
Dr. A.Antonelli SIN GI

% Ipertesi in Trattamento

% Ipertesi Controllati
Controllati

24%
47%

53%
29%
Non controllati

N...
USA

Canada
27 %

Italia

24 %

Germania

Dr. A.Antonelli SIN GI

Australia

16 %

Inghilterra

India

9 %

Finlandia

22....
Dr. A.Antonelli SIN GI

Stratification of Risk to Quantify Prognosis
1999 WHO-ISH Guidelines for the Managenent of Hyperte...
Dr. A.Antonelli SIN GI

Stratification of Risk to Quantify Prognosis
European Society of Hypertension Guidelines 2003

Alt...
Dr. A.Antonelli SIN GI

Quali sono i valori ottimali della
pressione arteriosa secondo i
criteri del JNC VII ?
1 - < 129/8...
Dr. A.Antonelli SIN GI

The Seventh report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treat...
Dr. A.Antonelli SIN GI

Factors influencing prognosis
Risk factors for cardiovascular disease used for
stratification

• L...
Clinical Conditions Associated

Dr. A.Antonelli SIN GI

• Cerebrovascular disease:
ischaemic stroke;
cerebral haemorrhage;...
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lessandro Antonelli: CONTROLLO OTTIMALE DELLA PRESSIONE ARTERIOSA dal congresso di Foligno del Gruppo Ipertensione della SIN

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lessandro Antonelli: CONTROLLO OTTIMALE DELLA PRESSIONE ARTERIOSA dal congresso di Foligno del Gruppo Ipertensione della SIN

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lessandro Antonelli: CONTROLLO OTTIMALE DELLA PRESSIONE ARTERIOSA dal congresso di Foligno del Gruppo Ipertensione della SIN

  1. 1. Dr. A.Antonelli SIN GI CONTROLLO OTTIMALE DELLA PRESSIONE ARTERIOSA Alessandro Antonelli U.O Nefrologia Ospedale Campo di Marte - Lucca 2° Corso Interattivo di Aggiornamento sulla “Ipertensione Arteriosa” IL DANNO D’ORGANO Foligno, 23-24 Ottobre 2003 Dr. A.Antonelli SIN GI Da oltre cento anni, da quando l’ipertensione fu chiaramente distinta dalla Malattia di Bright, si discute sul livello di pressione arteriosa da considerare patologico • “ Non esiste una vera demarcazione. Quanto più è elevata la pressione, tanto peggiore è la prognosi “ Pickering 1972 • “L’ipertensione è il livello al quale i benefici dell’intervento superano quelli dell’astensione “ Rose 1980 1
  2. 2. Dr. A.Antonelli SIN GI “ L’Ipertensione arteriosa è il livello di pressione per il quale i benefici (meno i rischi ed i costi ) dell’azione sono superiori ai rischi e ai costi ( meno i benefici ) dell’astensione “ Kaplan 1998 Dr. A.Antonelli SIN GI Prevalenza ipertensione % Prevalenza di ipertensione arteriosa in rapporto ad età e razza negli USA Maschi 80 70 60 50 Neri Bianchi Ispanici 40 30 20 10 0 18-29 30-39 40-49 50-59 Età anni 60-69 70-79 > 80 NHANES III, Hypertension 1995 2
  3. 3. Dr. A.Antonelli SIN GI Prevalenza ipertensione % Prevalenza di ipertensione arteriosa in rapporto ad età e razza negli USA Femmine 90 80 70 60 50 40 30 Neri Bianchi Ispanici 20 10 0 18-29 30-39 40-49 50-59 60-69 70-79 Età anni > 80 NHANES III, Hypertension 1995 Dr. A.Antonelli SIN GI 50 Cardiopatia ischemica normotesi N° eventi/2anni/1000 persone ipertesi 40 30 20 Scompenso cardiaco Arteriopatie periferiche Ictus 10 0 OR M F 22.7-11.8 M 9.1-3.8 F M F 4.9-5.3 M F 10.4-4.2 Kannel WB, JAMA 1996 3
  4. 4. Dr. A.Antonelli SIN GI Multiple Risk Factor Intervention Trial Causes of death, RR 3,5 3,2 3 2,5 2,5 2 3,0 2,8 2,3 1,5 1 0,5 0 All deaths CHD Stroke Other CVDs All CV deaths Stamler J. et al., Diabetes Care, 1993 Dr. A.Antonelli SIN GI Riduzione percentuale dei tassi di mortalità corretti per l’età negli USA % 1972 1975 1980 1985 1990 1995 10 0 -10 Malattie non CV -20 -30 -40 -50 Ictus Cardiopatia Ischemica -60 -70 National Center for Health Statistics, 1997 4
  5. 5. Dr. A.Antonelli SIN GI Trials exploring the optimal drug Trials comparing more intensive and less intensive blood pressure lowering strategies Dr. A.Antonelli SIN GI Prospectively designed overviews of randomised trials Trials comparing more intensive and less intensive blood pressure lowering strategies ABCD-hypert HOT UKPDS-HDS SBP -6 -3 -10 DBP -8 -3 -5 follow-up 5 4 8 Blood Pressure Lowering Treatment Trialist’ Collaboration, The Lancet, 356, 2000 5
  6. 6. Dr. A.Antonelli SIN GI Prospectively designed overviews of randomised trials Trials comparing more intensive and less intensive blood pressure lowering strategies Stroke 0.80 (0.65-0.98) CHD 0.81 (0.67-0.98) HF 0.78 (0.53-1.15) Major CV events 0.85 (0.76-0.96) CV deaths 0.90 (0.75-1.09) Total mortality 0.97 (0.85-1.11) 0.5 1 Favours more intensive Relative risk 2 Favours less intensive Blood Pressure Lowering Treatment Trialist’ Collaboration, The Lancet, 356, 2000 Dr. A.Antonelli SIN GI HOT Study: Significant Benefit from Intensive Treatment in the Diabetic Subgroup 25 20 Major cardiovascular 15 events/1,000 patient-years 10 p = 0.005 for trend 5 0 ≤ 90 ≤ 85 ≤ 80 mmHg Target Diastolic Blood Pressure Hansson L et al. Lancet 1998;351:1755-1762. 6
  7. 7. Dr. A.Antonelli SIN GI Trials exploring the optimal drug Trials comparing active treatment and placebo Dr. A.Antonelli SIN GI Prospectively designed overviews of randomised trials ACE-inhibitor-based therapy vs placebo HOPE PART2 QUIET SCAT SBP -3 -6 ---4 DBP -1 -4 ---3 follow-up 5 4 2 5 Blood Pressure Lowering Treatment Trialist’ Collaboration, The Lancet, 356, 2000 7
  8. 8. Dr. A.Antonelli SIN GI Prospectively designed overviews of randomised trials ACE-inhibitor-based therapy vs placebo Stroke 0.70 (0.57-0.85) CHD 0.80 (0.72-0.89) HF 0.84 (0.68-1.04) Major CV events 0.79 (0.73-0.86) CV deaths 0.74 (0.64-0.85) Total mortality 0.84 (0.76-0.94) 0.5 1 Favours ACEs Relative risk 2 Favours placebo Blood Pressure Lowering Treatment Trialist’ Collaboration, The Lancet, 356, 2000 Dr. A.Antonelli SIN GI Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. combined primary 0 -5 myocardial stroke cardio- infarction vascular mortality outcome 25% total revascularization death 22% 33% 37% overt nephro- heart failure pathy 24% 17% 24% 20% -10 -15 p=0.031 -20 -25 -30 -35 -40 % p=0.019 p=0.01 p=0.004 p=0.000 4 p=0.0074 p=0.027 p=0.0001 HOPE Study Investigators, The Lancet, 2000 8
  9. 9. Dr. A.Antonelli SIN GI Prospectively designed overviews of randomised trials Calcium-antagonist-based therapy vs placebo PREVENT SYST-EUR SBP -5 -10 DBP -4 -5 follow-up 3 2 Blood Pressure Lowering Treatment Trialist’ Collaboration, The Lancet, 356, 2000 Dr. A.Antonelli SIN GI Prospectively designed overviews of randomised trials Calcium-antagonist-based therapy vs placebo Stroke 0.61 (0.44-0.85) CHD 0.79 (0.50-1.06) HF 0.72 (0.48-1.07) Major CV events 0.72 (0.59-0.87) CV death 0.72 (0.52-0.98) Total mortality 0.87 (0.70-1.09) 0.5 Favours CCBs 1 Relative risk 2 Favours placebo Blood Pressure Lowering Treatment Trialist’ Collaboration, The Lancet, 356, 2000 9
  10. 10. Dr. A.Antonelli SIN GI Prospectively designed overviews of randomised trials ACE-inhibitors vs Calcium antagonists: a comparison “at distance” Stroke CHD HF Major CV events CV death Total mortality 0.5 Favours ACEc/CCBs 1 Relative risk 2 Favours placebo Blood Pressure Lowering Treatment Trialist’ Collaboration, The Lancet, 356, 2000 Dr. A.Antonelli SIN GI Cause principali di nuovi casi di ESRD negli USA (1997) Glomerulonefriti 9% Altre cause Altre cause 10% urologiche 2% Cisti 2% Diabete 43% Cause non note 9% Ipertensione 25% USRDS 1999 Renal Data Report 10
  11. 11. Dr. A.Antonelli SIN GI Ruolo dell’ipertensione arteriosa nel determinare il danno renale Ipertensione arteriosa (stadio III) Ipertensione arteriosa (stadio I- II) Fino a 10 anni fa prevaleva l’idea che fosse una situazione innocua per il rene Ben documentato Dr. A.Antonelli SIN GI <100 80 100-110 60 % >110 40 0 2 4 Time, years 6 8 MAP, mmHg Probability of survival 100 10 Renal survival probability in 423 patients with non diabetic renal disease and chronic renal failure Oldrizzi L, Am J Kidney Dis 1993 11
  12. 12. Dr. A.Antonelli SIN GI % Ipertesi in Trattamento % Ipertesi Controllati Controllati 24% 47% 53% 29% Non controllati Non trattati Trattati Burt et al; Hypertension 95 Dr. A.Antonelli SIN GI Qual’ è la prevalenza del controllo ottimale dell’ipertensione arteriosa in Italia ? 1 - 50% 2 - 32% 3 - 24% 12
  13. 13. USA Canada 27 % Italia 24 % Germania Dr. A.Antonelli SIN GI Australia 16 % Inghilterra India 9 % Finlandia 22.5 % 19 % 9 % Spagna 20.5 % 20 % Marques Am J Hypertens 2000 Dr. A.Antonelli SIN GI Stratification of Risk to Quantify Prognosis 1999 WHO-ISH Guidelines for the Managenent of Hypertension Other Risk Factors & Disease History Grade 1 (mild) Grade 2 (moderate) Grade 3 (severe) SBP 140-159 or DBP 90-99 SBP 160-179 or DBP 100-109 SBP >180 or DBP >110 I. no other risk factors LOW RISK MED RISK HIGH RISK II. 1-2 risk factors MED RISK MED RISK V HIGH RISK HIGH RISK HIGH RISK V HIGH RISK V HIGH RISK V HIGH RISK V HIGH RISK III. 3 or more risk factors or TOD or diabetes IV. ACC TOD - Target Organ Damage ACC - Associated Clinical Conditions, including clinical CVD or renal disease 13
  14. 14. Dr. A.Antonelli SIN GI Stratification of Risk to Quantify Prognosis 1999 WHO-ISH Guidelines for the Managenent of Hypertension Other Risk Factors & Disease History Grade 1 (mild) Grade 2 (moderate) SBP 140-159 or SBP 160-179 or DBP 90-99 DBP 100-109 Grade 3 (severe) SBP >180 or DBP >110 I. no other risk factors Lifestyle 12 Drug therapy Drug therapy II. 1-2 risk factors Lifestyle 6 Drug therapy Drug therapy III. 3 or more risk factors or TOD or diabetes Drug therapy Drug therapy Drug therapy IV. Drug therapy Drug therapy Drug therapy ACC TOD - Target Organ Damage ACC - Associated Clinical Conditions, including clinical CVD or renal disease Dr. A.Antonelli SIN GI Stratification of Risk to Quantify Prognosis 1999 WHO-ISH Guidelines for the Managenent of Hypertension Other Risk Factors & Disease History HighNormal Grade 1 (mild) Grade 2 (moderate) Grade 3 (severe) Drug therapy SBP 130-139 SBP 140-159 or SBP 160-179 or SBP >180 or DBP 85-89 DBP 90-99 DBP 100-109 DBP >110 I. no other risk factors Lifestyle Lifestyle 12 Drug therapy II. 1-2 risk factors Lifestyle Lifestyle 6 Drug therapy Drug therapy III. 3 or more risk factors or TOD or diabetes Drug therapy Drug therapy Drug therapy Drug therapy IV. Drug therapy Drug therapy Drug therapy Drug therapy ACC TOD - Target Organ Damage ACC - Associated Clinical Conditions, including clinical CVD or renal disease 14
  15. 15. Dr. A.Antonelli SIN GI Stratification of Risk to Quantify Prognosis European Society of Hypertension Guidelines 2003 Altri fattori di rischio e anamnesi I.no other risk factors Normale Normale alta Grado 1 Grado 2 PAS 120-129 PAS 130-139 PAS 140-159 PAS 160-179 o PAD 80-84 RANGE RISK o PAD 85-89 RANGE RISK LOW RISK MED RISK LOW RISK MED RISK MED RISK II.1-2 risk factors LOW RISK III.3 or more risk factors or TOD or diabetes MED RISK HIGH RISK IV ACC HIGH RISK V HIGH RISK Grado 3 PAS >180 o PAD 90-99 o PAD 100-109 DBP >110 HIGH RISK V HIGH RISK HIGH RISK V HIGH RISK HIGH RISK V HIGH RISK V HIGH RISK V HIGH RISK TOD - Target Organ Damage ACC - Associated Clinical Conditions, including clinical CVD or renal disease Dr. A.Antonelli SIN GI Soglia di intervento Obiettivi del trattamento PAS PAD PAS PAD National Joint Committee VI 1997 In presenza di proteinuria>1g/24h 130 85 <130 <125 <85 <75 Italian Hypertension Guidelines 140 90 <130 <85 140 90 140 90 <130 <130 <125 <135 <125 <85 <80 <75 <85 <75 140 90 <130 <80 1999 World Health Organization & International Society of Hypertens 1999 In presenza di proteinuria<1g/24h In presenza di proteinuria>1g/24h German Hypertension Guidelines In presenza di proteinuria>1g/24h 2002 American Diabetes Association 2002 15
  16. 16. Dr. A.Antonelli SIN GI Quali sono i valori ottimali della pressione arteriosa secondo i criteri del JNC VII ? 1 - < 129/84 mmHg 2 - < 120/80 mmHg 3 - < 140/90 mmHg Dr. A.Antonelli SIN GI The Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Classification and Management of Blood Pressure Normal With compelling indications Stage 1 Hypertension Stage 2 hypertension SBP <120 DBP <80 Lifestyle modification Prehypertension SBP 120-139 DBP 80-89 SBP 140-159 DBP 90-99 SBP >159 DBP >99 Encourage Yes Yes Yes Drug(s) for the compelling indications Drug(s) for the compelling indications Drug(s) for the compelling indications The JNC 7 Report, JAMA 289: 2560-2572, 2003 16
  17. 17. Dr. A.Antonelli SIN GI The Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Compelling Indications for Individual Drug Classes High-Risk Conditions with compelling indications Diuretic ß-Blocker ACE inhibitor ARB CCB Aldosterone antagonist Heart failure Post-myocardial infarction High coronary disease risk DIABETES Chronic kidney disease Recurrent stroke prevention The JNC 7 Report, JAMA 289: 2560-2572, 2003 Dr. A.Antonelli SIN GI Quali dei seguenti sono fattori utilizzati per la stratificazione del rischio cardiovascolare ? 1 2 3 4 5 6 - Dislipidemia - Abitudine al fumo - Microalbuminuria - Obesità addominale - Nefropatia Diabetica - Proteina C Reattiva 17
  18. 18. Dr. A.Antonelli SIN GI Factors influencing prognosis Risk factors for cardiovascular disease used for stratification • Levels of systolic and diastolic BP • Men >55 years • Women > 65 years • Smoking • Dyslipidaemia (total cholesterol >6.5 mmol/l, >250 mg/dl, or LDL-cholesterol > 4.0 mmol/l, >155 mg/dl, or HDL-cholesterol M < 1.0,W < 1.2 mmol/l, M < 40,W < 45 mg/dl) • Family history of premature cardiovascular disease (at age < 55 years M, < 65 years W) • Abdominal obesity (abdominal circumference M > 102 cm, W> 88 cm) • C-reactive protein >1 mg/dl TARGET ORGAN DAMAGE Dr. A.Antonelli SIN GI • Left ventricular hypertrophy (electrocardiogram: Sokolow–Lyons .38 mm; Cornell .2440 mm_ms; echocardiogram: LVMI M > 125, W> 110 g/m2) • Ultrasound evidence of arterial wall thickening (carotid IMT > 0.9 mm) or atherosclerotic plaque • Slight increase in serum creatinine (M 115–133,W 107– 124 _mol/l; M 1.3–1.5,W1.2–1.4 mg/dl) • Microalbuminuria (30–300 mg/24 h; albumin–creatinine ratio M > 22,W >31 mg/g; M > 2.5,W > 3.5 mg/mmol) 18
  19. 19. Clinical Conditions Associated Dr. A.Antonelli SIN GI • Cerebrovascular disease: ischaemic stroke; cerebral haemorrhage; transient ischaemic attack • Heart disease: myocardial infarction; angina; coronary revascularization; congestive heart failure • Renal disease: diabetic nephropathy; renal impairment (serum creatinine M >133, W>124 umol/l;M >1.5,W>1.4 mg/dl) proteinuria (>300 mg/24 h) • Peripheral vascular disease • Advanced retinopathy: haemorrhages or exudates, papilloedema CONCLUSIONI Hypertension: Dr. A.Antonelli SIN GI “test of vascular health” “important target in the prevention of cardiovascular disease” T.D. Giles New York ASH 15/5/2003 • Le nostre conoscenze sull’ipertensione arteriosa sono notevolmente aumentate negli anni ed è il momento di valorizzarle trasformandole in comportamenti di buona pratica clinica. • Le linee guida diagnostiche terapeutiche delle diverse comunità scientifiche rappresentano una ulteriore risorsa per raggiungere il controllo ottimale della pressione arteriosa. 19

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