Dr. Carlos Guijarro. Madrid

Transcripción

1 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

2 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

3 Ischemic Heart Disease Mortality HTA y mortalidad cardiovascular CHD Usual Systolic BP (mm Hg) Stroke Mortality Stroke Usual Systolic BP (mm Hg) Prospective Studies Collaboration. Lancet. 2002;360:

4 Factores de riesgo vascular una relación de ida y vuelta? Eventos vasculares Intervención Factor de riesgo Epidemiología

5 Factores de riesgo vascular una relación de ida y vuelta? Eventos vasculares Intervención cuánto, cómo? Epidemiología Factor de riesgo

6 Age-adjusted death rates for diseases of the heart, cerebrovascular disease, by year USA Statins Effective BP Treatments effective Stroke 2013 DOI: /01.str cf

7 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

8 Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus The ACCORD Study Group N Engl J Med Apr 29;362(17):

9 2013 ESH/ESC Guidelines for the management of arterial hypertension SBP < 140 mmhg DBP < 90 / 85 mmhg Journal of Hypertension 2013, 31:

10 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. JNC 8 > 60 yr < 60 yr DM CKD 150/90 140/90 JAMA. doi: /jama Published online December 18, 2013

11 Combined RAS for diabetics? ON TARGET 2,4 mmhg ALTITUDE STOP N Engl J Med 2012;367: STOP VA-NEPHRON N Engl J Med 2008;358: N Engl J Med 2013;369:

12 2013 ESH/ESC Guidelines for the management of arterial hypertension JNC Do not use an ACEI and anarb together in the same patient. J Hypertension 2013, 31: JAMA. doi: /jama

13 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

14 PROVE-IT: J curve? Blood pressure vs LDL levels NADIR SBP MHG Referent Hazard Ratio 1 0 Bangalore et al.circulation. 2010;122:2142 < > LDL Wiviott SD et al. JACC. 2005;46:1411.

15 Age-and Sex-Adjusted Incidence Rates of Acute Myocardial Infarction, 1999 to CGH 2011 Yeh RW et al. N Engl J Med 2010;362:

16 Association of Temporal Trends in Risk Factors and Treatment Uptake With Coronary Heart Disease Mortality, Factores que explica la reducción en mortalidad (Ontario Canadá) JAMA. 2010;303(18):

17 +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. Davidson: Circulation, Volume 111(18).May 10,

18 Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from participants in 14 randomised trials of statins Cholesterol Treatment Trialists (CTT) Collaborators* Lancet 2005; 366:

19 Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from participants in 26 randomised trials Cholesterol Treatment Trialists (CTT) Collaborators* Irrespective of baseline LDL cholesterol levels CGH 2010 The Lancet 2010 Nov DOI: /S (10)

20 Colesterol y mortalidad CV De la epidemiología al tratamiento 256 Edad Edad: Hazard ratio& 95% CI Colesterol total (mmol/l) Hazard ratio (& 95% CI) años Col HDL (mmol/l)? PSC Prospective Studies Collaboration Lancet 2007; 370:

21 N Engl J Med. 2010;362:1563 Fenofibrate N Engl J Med 2012;367:

22 Percent Reduction in Primary CV Event Rate vs. Placebo (%) Lipid Drug Trials: Relative Reduction in Clinical Events ACCORD ILLUMINATE HPS2 THRIVE DAL OUTCOMES % HDL-C C Minus % % LDL-C in Rx (%) Placebo-Adjusted FIELD VA-HIT AFREGS LIPID CARE POSCH 4S FATS-NC HATS IDEAL TNT Curr Opin Lipidol 2006;17: N Engl J Med ;357:2109 FATS-L+C N Engl J Med. 2012;367:2089 N Engl J Med. 2010;362:1563 ACC 2013

23 LDL Mendelian randomization LDL vs HDL & CV risk HDL 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 Plasma HDL cholesterol and risk of myocardial infarction: a mendelian randomisation study Lancet May 17, 2012; DOI: /S (12)

24 Mendelian randomization LDL vs HDL & CV risk Plasma HDL cholesterol and risk of myocardial infarction: a mendelian randomisation study Lancet May 17, 2012; DOI: /S (12)

25 Plasma HDL cholesterol and risk of myocardial infarction: a mendelian randomisation study Odds Ratio per SD 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. Published online May 17, 2012 DOI: /S (12)