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Casablanca, le 30 Avril 2011

MEDITERANEAN GROUP FOR STUDY DIABETES. BLOOD PRESSURE. IS THE LOWER THE BETTER?. Cont :. Faiçal JARRAYA, MD, Pr Ag ESH Hypertension specialist Service de Néphrologie, CHU Hédi Chaker ,& UR Pathologie Rénale, Faculté de Médecine Sfax

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Casablanca, le 30 Avril 2011

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  1. MEDITERANEAN GROUP FOR STUDY DIABETES BLOOD PRESSURE IS THE LOWER THE BETTER? Cont: Faiçal JARRAYA, MD, Pr Ag ESH Hypertension specialistService de Néphrologie, CHU HédiChaker,& UR Pathologie Rénale, Faculté de Médecine Sfax Unité Cibles pour le Diagnostic et la Thérapie. CBSLIA CNRS 135 « Gènes & Protéines dans les maladies multi géniques» jarraya_faical@yahoo.fr Casablanca, le 30 Avril 2011

  2. IHD and Stroke relateddeathregarding to age and systolicblood pressure level a metaanalysis ? ? Stroke IHD Prospective Studies Collaboration, Lancet 2002

  3. BLOOD PRESSURE GOAL FOR DIABETIC PATIENTS Guidelines C Level of evidence Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA. 2003;289:2560–2572. World Health Organization, International Society of Hypertension Writing Group. 2003 World Health Organization (WHO⁄ International Society of Hypertension (ISH) statement on management of hypertension. J Hypertens. 2003;21:1983–1992. Williams B, Poulter NR, Brown MJ, et al. British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. BMJ. 2004;328:634–640. Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2007;25:1105–1187. Rosendorff C, Black HR, Cannon CP, et al. Treatment of hypertension in the prevention and management of ischemic heart disease. A scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation. 2007;115:2761–2788. American Diabetes Association. Standards of medical care in diabetes – 2008. Diabetes Care. 2008;31(suppl 1):S12–S54.

  4. Achieved systolic blood pressure (SBP) in diabetic patients included intrials comparing placebo (or less intense) with more intenseantihypertensive treatment (ordinates at left), and reductions in majorcardiovascular (CV) events (ordinates at right). Zanchetti et al. Journal of Hypertension 2009,

  5. ABCD 137±0.7/81±0.3 mm Hg 128±0.8/75±0.3 mm Hg RW Schrier et al. Kidney Int 2002;61:1086-97.)

  6. CV outcomes according to intervention: Intensive vs moderate ABCD RW Schrier et al. Kidney Int 2002;61:1086-97

  7. INVEST >140mmHg <130mmHg 130-140mmHg Cooper-DeHoff RM et al. JAMA 2010;304:61-8

  8. INVEST Cooper-DeHoff RM et al. JAMA 2010;304:61-8

  9. N Engl J Med 362;17 nejm.org april 29, 2010 N Engl J Med 2010;362:1575-85. Mean # Meds Intensive: 3.2 3.4 3.5 3.4 Standard: 1.9 2.1 2.2 2.3 Average : 133.5 Standard vs. 119.3 Intensive, Delta = 14.2

  10. ACCORD BP Les patients inclus sont âgés et souvent non proteinuriques S t u d y • Stable Type 2 Diabetes >3 months • HbA1c 7.5% to 11% (or <9% if on more meds) • High CVD risk = clinical or subclinical disease or>2 risk factors • Age (limited to <80 years after Vanguard) • ≥ 40 yrs with history of clinical CVD (secondary prevention) • ≥ 55 yrs otherwise • Urine protein <1.0 gm/24 hours or equivalent • Serum Creatinine <1.5 mg/dl *Median value

  11. Dogma Disputed: Can Aggressively Lowering Blood Pressure in Hypertensive Patients with Coronary Artery Disease Be Dangerous? F Messerli et al. Ann Intern Med. 2006;144:884-893. Secondary analysis of data from INVEST

  12. INVEST F Messerli et al. Ann Intern Med. 2006;144:884-893.

  13. CORONARY BLOOD FLOW ON DIASTOLE

  14. META ANALYSE DES CORRLATION ENTRE FONCTION RENALE & PRESSION ARTERIELLE Bakris GL et al. Am J Kidney Dis 2000; 36(3): 646-661 1 PAM (mmHg) 95 98 101 104 107 110 113 116 119 0 Modification du DFG2 (ml/min/an) -2 r = 0.69; P < 0.05 -4 -6 -8 HTA non traitée -10 -12 130/85 140/90 -14 1 Préssion artérielle moyenne 2 Débit de filtration glomérulaire

  15. Independent and Additive Impact of BP Control and ARB on Renal Outcomes in the Irbesartan Diabetic Nephropathy Trial: Clinical Implications and Limitations IDNT trial M A Pohl et al. J Am Soc Nephrol 2005.

  16. ANNUAL ESRD AND MORTALITY IN TYPE 2 DIABETICS WITH OVERT NEPHROPATHY 25 ° Renal failure in type 2 diabetes “a medical catastrophe of world-wide dimension” Ritz, AJKD (1999) 34: 795 (%) 20 15 10 * 5 0 ESRD Mortality Estimate from the °UKPDS and the *RENAAL studies Adler et al., Kidney Int, 2003

  17. When should antihypertensive drug treatment be initiated and to what levels should systolic blood pressure be lowered? A critical reappraisal A Zanchetti, Guido Grassi, G Mancia: Wisdom should not be taken for evidence Journal of Hypertension 2009, 27:923–934

  18. CV Mortality BP BP GOAL IN HYPERTENSIVE TREATYED PATIENT: The lower, NOT the better Reappraisal ESH 2009 The Curve Reappraisal ESH 2009 ESH 2007 G Mancia et al ESH 2007 & Reappraisal 2009Journal of hyprttrsion

  19. 2073 patients Peripheral SBP: difference 0,7 mm Hg (p < 0,2) Central SBP: difference 4,3 mm Hg (p < 0,0001) amlodipine + Perindopril atenolol + thiazide

  20. Sfax, 13th century monument

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