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BENEFICIOS DEL TRATAMIENTO DE LA HIPERTENSIÓN ARTERIAL

BENEFICIOS DEL TRATAMIENTO DE LA HIPERTENSIÓN ARTERIAL. PROF. DR. JORGE RESK HOSPITAL NACIONAL DE CLINICAS UNIVERSIDAD NACIONAL DE CORDOBA. BLOOD PRESSURE, STROKE, AND CORONARY HEART DISEASE. The Lancet 1990; 335: 827-838. 1000. ALL AVAILABLE EVIDENCE FROM RANDOMISED . T = TREATMENT.

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BENEFICIOS DEL TRATAMIENTO DE LA HIPERTENSIÓN ARTERIAL

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  1. BENEFICIOS DEL TRATAMIENTODE LA HIPERTENSIÓN ARTERIAL PROF. DR. JORGE RESK HOSPITAL NACIONAL DE CLINICAS UNIVERSIDAD NACIONAL DE CORDOBA

  2. BLOOD PRESSURE, STROKE, AND CORONARY HEART DISEASE The Lancet 1990; 335: 827-838. 1000 ALL AVAILABLE EVIDENCE FROM RANDOMISED T = TREATMENT ANTIHYPERTENSIVE DRUG TRIALS C = CONTROL (mean DBP difference 5-6 mmHg for 5 years) = FATAL EVENTS = NON FATAL EVENTS 771 800 671 613 600 489 484 Total numbers of individuals affected 401 396 400 356 289 316 200 97 160 86 87 0 T C T C T C T C T C REMAINING ALL ALL STROKE CHD VASCULAR VASCULAR OTHER % reduction DEATHS* DEATHS* DEATHS in odds 42% SD 6 14% SD 5 2P-value <0.0001 <0.01 <0.0002

  3. BENEFICIOS DEL TRATAMIENTO ANTIHIPERTENSIVO • Reducción significativa de la morbilidad y mortalidad cardiovascular. • Reducción menos significativa sobre todas las causas de muerte. • Los beneficios se observan en individuos de edad avanzada, incluso en pacientes con hipertensión arterial sistólica aislada. • Reducción del riesgo cardiovascular en hombres y mujeres. • Hay mayor reducción del riesgo de ACV (30 a 40%) que de ECo (20%). • Probablemente produce una reducción significativa en la incidencia de insuficiencia cardíaca.

  4. ADVERSE OUTCOMES IN PLACEBO-CONTROLLED TRIALS WITH FIRST-LINE THIAZIDE OR b-BLOCKERS TREATMENT, Nº OF PATIENTS RR OUTCOME THIAZIDE PLACEBO (95% CI) 0.59 * STROKE 284 584 (0.51-0.68) 0.84 * CAD 433 703 (0.75-0.95) 0.70 * ANY CV EVENT 838 1512 (0.64-0.75) 0.90 * DEATH 742 1097 (0.82-0.98) TOTAL OF 12118 17233 PATIENTS * P <0.05 WRIGHT JM ET AL. CMAJ 1999; 161: 25-32

  5. RANDOMIZED CONTROLLED TRIALS IN HYPERTENSION: FIRST DRUG THERAPY RELATIVE RISK VS PLACEBO CV STROKE CHD CHF MORTALITY HIGH DOSE DIURETIC 0,49 0,99 0,17 0,78 (50-100 mg) LOW DOSE DIURETIC 0,66 0,72 0,58 0,76 (12.5-25 mg) BETA-BLOCKER 0,71 0,93 0,58 0,89 CHD: CORONARY HEART DISEASE CHF: CONGESTIVE HEART FAILURE PSATY BM, SMITH NL, SISCOVICK DE, ET AL. JAMA 1997; 277: 739-745.

  6. THE BLOOD PRESSURE LOWERING TREATMENT TRIALISTS’ COLLABORATION CALCIUM CHANNEL BLOCKERS vs PLACEBO * BORDERLINE STATISTICAL SIGNIFICANCE. LANCET 2003; 362: 1527-35.

  7. THE BLOOD PRESSURE LOWERING TREATMENT TRIALISTS’ COLLABORATION CALCIUM CHANNEL BLOCKERS vs DIURETICS / b-BLOCKERS * HIGHLY STATISTICAL SIGNIFICANCE. LANCET 2003; 362: 1527-35.

  8. THE BLOOD PRESSURE LOWERING TREATMENT TRIALISTS’ COLLABORATION ANGIOTENSIN CONVERTING ENZIME INHIBITORS vs PLACEBO * HIGHLY STATISTICAL SIGNIFICANCE. LANCET 2003; 362: 1527-35.

  9. THE BLOOD PRESSURE LOWERING TREATMENT TRIALISTS’ COLLABORATION ACE-INHIBITORS vs DIURETICS / b-BLOCKERS LANCET 2003; 362: 1527-35.

  10. THE BLOOD PRESSURE LOWERING TREATMENT TRIALISTS’ COLLABORATION ACE-INHIBITORS vs CALCIUM CHANNEL BLOCKERS * HIGHLY STATISTICAL SIGNIFICANCE. LANCET 2003; 362: 1527-35.

  11. EFECTOS DEL TRATAMIENTO ANTIHIPERTENSIVO ANTAGONISTAS DE LOS RECEPTORES DE ANGIOTENSINA VS OTROS TRATAMIENTOS ARCH INTERN MED 2005; 165: 1410-1419.

  12. ADVERSE OUTCOMES IN PLACEBO-CONTROLLED TRIALS WITH FIRST-LINE THIAZIDE OR b-BLOCKERS TREATMENT, Nº OF PATIENTS RR b -BLOCKER OUTCOME PLACEBO (95% CI) 0.80 STROKE 98 243 (0.64-1.01) 0.92 CAD 183 393 (0.78-1.10) 0.89 ANY CV EVENT 297 661 (0.78-1.02) 1.01 DEATH 287 568 (0.88-1.15) TOTAL OF 5505 10867 PATIENTS WRIGHT JM ET AL. CMAJ 1999; 161: 25-32

  13. LIFE STUDY LANCET 2002; 359:995-1003. PRIMARY AND SECONDARY OUTCOMES Adjusted* LosartanAtenolol RR p(n=4605) (n=4588) (%) Primary composite** 508 588 -13 0.021 CV mortality 204 234 -11 0.206 Stroke 232 309 -25 0.001 MI 198 188 +7 0.491 Total mortality 383 431 -10 0.128 * For degree of LVH and Framingham risk score at randomization ** CV mortality, stroke and MI; patients with a first primary event

  14. Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA) STROKE TOTAL CV EVENTS LANCET 2005; 366:895-906.

  15. Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA) CV MORTALITY TOTAL MORTALITY LANCET 2005; 366:895-906.

  16. Should b-Blockers Remain First Choice in the Treatment of Primary Hypertension? A Meta-Analysis • FINDINGS: • When the effect of b-blockers was compared with that placebo or no treatment, the relative risk of stroke was reduced by 19% (7-29%), about half that expected from previous hypertension trials. • There was no difference for myocardial infarction or mortality. LANCET 2005; 366:1545-1553.

  17. Should b-Blockers Remain First Choice in the Treatment of Primary Hypertension? A Meta-Analysis • CONCLUSIONS: • Hence, we believe that b-blockers should not remain first choice in the treatment of primary hypertension. LANCET 2005; 366:1545-1553.

  18. HOW STRONG IS THE EVIDENCE FOR USE OF b-BLOCKERS AS FIRST LINE THERAPY FOR HYPERTENSION? SYSTEMATIC REVIEW AND META-ANALYSIS J HYPERTENS 2006; 24: 2131-2141.

  19. HOW STRONG IS THE EVIDENCE FOR USE OF b-BLOCKERS AS FIRST LINE THERAPY FOR HYPERTENSION? SYSTEMATIC REVIEW AND META-ANALYSIS J HYPERTENS 2006; 24: 2131-2141.

  20. HOW STRONG IS THE EVIDENCE FOR USE OF b-BLOCKERS AS FIRST LINE THERAPY FOR HYPERTENSION? SYSTEMATIC REVIEW AND META-ANALYSIS • CONCLUSIONS: • b-blockers are inferior to CCBs and to RAS inhibitors for reducing several important hard end points. • Compared with diuretics, they had similar outcomes, but were less will tolerated. • Hence, b-blockers are generally suboptimal first-line antihypertensive drugs. J HYPERTENS 2006; 24: 2131-2141.

  21. ALLHATJAMA Dec 2002; 288: 2981-2997 INTERVENTIONS GOAL BLOOD PRESSURE WAS LESS THAN 140/90 mm Hg DOSE (mg/d) n STEP 1 DRUGS 12.5 TO 25 15255 CHLORTHALIDONE 2.5 TO 10 9048 AMLODIPINE 10 TO 40 9054 LISINOPRIL STEP 2 DRUGS 25 TO 100 ATENOLOL 0.05 TO 0.2 RESERPINE 0.1 TO 0.3 CLONIDINE STEP 3 DRUG 25 TO 100 HYDRALAZINE

  22. ALLHATJAMA Dec 2002; 288: 2981-2997 PRIMARY OUTCOME FATAL CHD OR NON-FATAL MYOCARDIAL INFARCTION RR 95% CI 0,98 0,90-1,07 AMLODIPINE vs CHLORTHALIDONE 0,99 0,91-1,08 LISINOPRIL vs CHLORTHALIDONE

  23. ALLHATJAMA Dec 2002; 288: 2981-2997 SECONDARY OUTCOME RR 95% CI AMLODIPINE vs CHLORTHALIDONE 1,38 1,25-1,52 HEART FAILURE LISINOPRIL vs CHLORTHALIDONE 1,10 1,05-1,16 COMBINED CV DISEASE 1,15 1,02-1,30 STROKE 1,19 1,07-1,31 HEART FAILURE

  24. 2007 GUIDELINES FOR THE MANAGEMENT OF ARTERIAL HYPERTENSION (ESH/ESC) • IN ANY CASE, THE ABOVE QUOTED META-ANALYSIS OF BETA BLOCKERS INITIATED TRIALS WELL ILLUSTRATE THE DIFFICULTIES INHERENT IN MANY RECENT TRIALS IN WHICH COMBINATION THERAPY HINDERS THE ATTRIBUTION OF EITHER BENEFITS OR HARMS TO INDIVIDUAL COMPOUNDS.

  25. EFECTOS DEL TRATAMIENTO ANTIHIPERTENSIVO MAS INTENSO VS MENOS INTENSO ARCH INTERN MED 2005; 165: 1410-1419.

  26. 2007 Guidelines for Management of Arterial Hypertension(J Hypertens 2007; 25: 1105-87) • CONCLUSIONES: • Hay un efecto beneficioso sobre la morbilidad y mortalidad cardiovascular cuando el tratamiento es iniciado con un diurético, bloqueante beta, calcio antagonista o inhibidor de la enzima de conversión. • La disminución de la presión arterial parece ser el determinante más importante para reducir la incidencia del accidente cerebrovascular y eventos coronarios.

  27. 2007 Guidelines for Management of Arterial Hypertension(J Hypertens 2007; 25: 1105-87) • CONCLUSIONES: • Algunos agentes antihipertensivos pueden ejercer un efecto beneficioso sobre determinados eventos en forma independiente al descenso de la presión arterial (calcio antagonistas sobre ACV e inhibidores ECA sobre eventos coronarios), aunque este efecto es definitivamente más pequeño que el efecto protector dominante ejercido por el descenso de la presión arterial.

  28. 2007 Guidelines for Management of Arterial Hypertension(J Hypertens 2007; 25: 1105-87) • CONCLUSIONES: • En general se ha reportado una menor protección de los calcio antagonistas en la prevención de nuevo comienzo de insuficiencia cardíaca independiente de las diferencias en la presión arterial. • Una disminución más intensa de la presión arterial produce una reducción mayor del ACV y de todos los eventos cardiovasculares, particularmente en pacientes diabéticos. • Los bloqueantes de los receptores de angiotensina también son efectivos para reducir los eventos cardiovasculares.

  29. G R A C I A S

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