¿Qué Hemos Aprendido en la Prevención sobre la Hipertensión y la Hipercolesterolemia? Lessons from Intervention on Risk Factors – Hypertension and Hyp...
¿Qué Hemos Aprendido en la Prevención sobre la Hipertensión y la Hipercolesterolemia? Lessons from Intervention on Risk Factors – Hypertension and Hypercholesterolemia. What’s new?
Dr. Carlos Guijarro
Madrid
FACTORES DE RIESGO Y PREVENCIÓN
¿Qué hemos aprendido?
• De la epidemiología al tratamiento • Reducción de complicaciones cardiovasculares • HTA – Efecto J. – Combinaciones peligrosas
• Dislipemia – Estatinas: no efecto J. Suelo? – HDL ¿cuál es su papel? – LDL en la diana: más allá de las estatina
HTA y mortalidad cardiovascular
Stroke
80-89
256
128
70-79
128
64
60-69
64
32
50-59
256
16
40-49
8 4
Stroke Mortality
Ischemic Heart Disease Mortality
CHD
4
1
0
0 180
Usual Systolic BP (mm Hg)
50-59
8
1
160
60-69
16
2
140
70-79
32
2
120
80-89
120
140
160
180
Usual Systolic BP (mm Hg) Prospective Studies Collaboration. Lancet. 2002;360:1903-1913
Factores de riesgo vascular
Eventos vasculares
¿una relación de ida y vuelta?
Intervención
Epidemiología Factor de riesgo
Factores de riesgo vascular Eventos vasculares
¿una relación de ida y vuelta? Intervención ¿cuánto, cómo?
Epidemiología Factor de riesgo
Age-adjusted death rates for diseases of the heart, cerebrovascular disease, by year USA
BP lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials “All the classes of blood pressure lowering drugs have a similar effect in reducing CHD events and stroke for a given reduction in blood pressure”
Law BMJ 2009;338:b1665
Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus The ACCORD Study Group
N Engl J Med. 2010 Apr 29;362(17):1575-85
2013 ESH/ESC Guidelines for the management of arterial hypertension
2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults . JNC 8
> 60 yr 150/90
< 60 yr
DM 140/90
JAMA. doi:10.1001/jama.2013.284427 Published online December 18, 2013
CKD
Combined RAS for diabetics? ON TARGET
STOP ALTITUDE
↓2,4 mmHg N Engl J Med 2012;367:2204-13
VA-NEPHRON
N Engl J Med 2008;358:1547-59
STOP
N Engl J Med 2013;369:1892-903.
2013 ESH/ESC Guidelines for the management of arterial hypertension
JNC 8 2014 Do not use an ACEI and an ARB together in the same patient. JAMA. doi:10.1001/jama.2013.284427
J Hypertension 2013, 31:1281–1357
FACTORES DE RIESGO Y PREVENCIÓN
¿Qué hemos aprendido?
• De la epidemiología al tratamiento • Reducción de complicaciones cardiovasculares • HTA – Efecto J. – Combinaciones peligrosas
• Dislipemia – Estatinas: no efecto J. Suelo? – HDL ¿cuál es su papel? – LDL en la diana: más allá de las estatina
PROVE-IT: J curve ? Blood pressure vs LDL levels 0.80
40-60
60-80
1
Hazard Ratio
0.67
80-100
Bangalore et al.Circulation. 2010;122:2142
Wiviott SD et al. JACC. 2005;46:1411.
Age- and Sex-Adjusted Incidence Rates of Acute Myocardial Infarction, 1999 to 2008.
CGH 2011 Yeh RW et al. N Engl J Med 2010;362:2155-2165.
Association of Temporal Trends in Risk Factors and Treatment Uptake With Coronary Heart Disease Mortality, 1994-2005
Factores que explica la reducción en mortalidad (Ontario – Canadá)
JAMA. 2010;303(18):1841-1847
+20
Meta-regression analysis CHD (nonfatal AMI + CHD death). Relationship Between % cholesterol reduction and Event Rates
Non-statin Trials
Statin Trials
VA-HIT Veterans Affairs High-Density Lipoprotein Intervention Trial; LRC-CPPT, Lipids Research Clinics Coronary Primary Prevention Trial; A to Z, Aggrastat to Zocor; CDP, Coronary Drug Project; HHS, Health and Human Services; CARE, Cholesterol and Recurrent Events; POSCH, Program on the Surgical Control of the Hyperlipidemias; ASCOT-LLA, Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm; LIPS, Lescol Intervention Prevention Study; 4S, Scandinavian Simvastatin Survival Study.
Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90 056 participants in 14 randomised trials of statins Cholesterol Treatment Trialists’ (CTT) Collaborators*
Lancet 2005; 366: 1267–78
Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170 000 participants in 26 randomised trials
Lipid Drug Trials: Relative Reduction in Clinical Events
ILLUMINATE Percent Reduction in Primary CV Event Rate vs. Placebo (%)
ACCORD HPS2 THRIVE DAL OUTCOMES 0 FIELD VA-HIT
-20
AFREGS LIPID CARE
-40
POSCH 4S
-60
FATS-NC HATS IDEAL
-80
TNT FATS-L+C
-100
0 25 50 75 %∆ HDL-C Minus %∆ LDL-C in Rx (%) Placebo-Adjusted Curr Opin Lipidol 2006;17:631-636. N Engl J Med. 2007 ;357:2109 N Engl J Med. 2012;367:2089 N Engl J Med. 2010;362:1563 ACC 2013
Mendelian randomization LDL vs HDL & CV risk LDL
Lifelong Reduction of LDL-Cholesterol Related to a Common Variant in the LDL-Receptor Gene Decreases the Risk of Coronary Artery Disease—A Mendelian Randomisation Study PLoS ONE. 2008; 3(8): e2986
HDL
Plasma HDL cholesterol and risk of myocardial infarction: a mendelian randomisation study Lancet May 17, 2012; DOI:10.1016/S0140-6736(12)60312-2
Mendelian randomization LDL vs HDL & CV risk
Plasma HDL cholesterol and risk of myocardial infarction: a mendelian randomisation study Lancet May 17, 2012; DOI:10.1016/S0140-6736(12)60312-2
Odds Ratio per SD
Plasma HDL cholesterol and risk of myocardial infarction: a mendelian randomisation study
Estimate of the association of genetically raised LDL cholesterol or HDL cholesterol and risk of myocardial infarction using multiple genetic variants as instruments LDL genetic score 13 SNPs) HDL genetic score 14 SNPs.
www.thelancet.com Published online May 17, 2012 DOI:10.1016/S0140-6736(12)60312-2
