Professional Documents
Culture Documents
Risk Factors
Subclinic TOD
HVI
Microalbuminuria
Creatinina >1.3mg/dl
IMT Elevado
Rigidez Vascular Vascular
Retinopata Hipertensiva
(grado III/IV)
Clinical Events
CHD
MI
CHF
ACV, TIA
IRC
Enfermedad Arterial
Perifrica
TG elevados
LDLcol Elevado
Sobre Peso/Obesidad
(BMI>25Kg/m2)
Menopausia
Posicin Social/Economica**
Nivel de Educacin
J Hypertens 2009; 27: 905-822
INTERHEART:MultipleRiskFactors.
ImpactonCVRisk
512
2.9
2.4
1.9
3.3
13.0
42.3
68.5
182.9
333.7
256
128
Tasa de
Probab.
del
1*IMA
64
(99% IC)
32
16
20 veces
de riesgo
4
2
1
Tabaco
(1)
52 pases
12,461casos
12,467 controles
DM
(2)
HTA
(3)
ApoB- 1+2+3
ApoA1
(4)
Los 4
Los 4
Los 4
+ Obes + Estres
Todos
los F.R
HYPERTENSION
Optimal
Normal
High
Normal
Grade 1
Grade 2
Grade 3
Mean Risk
Mean Risk
Mean Risk
Low Added
Risk
Moderate
Added Risk
High Added
Risk
1-2 RF or Social
Conditions of Risk
Low
Added
Risk
Low Added
Risk
Low Added
Risk0
Moderate
Added Risk
Moderate
Added Risk
Very High
Added Risk
3 RF or Social
Conditions of Risk
TOD or SM/DBT
Moderate
Added
Risk
Moderate
Added Risk
ModerateHigh Added
Risk
High Added
Risk
High Added
Risk
Very High
Added Risk
High
Added
Risk
High Added
Risk
Very High
Added
Risk
Very High
Added Risk
Very High
Added Risk
Very High
Added Risk
No RF
Clinical
Associated
Condition
Latin American guidelines on hypertension. Sanchez RA on behalf of the Latin America Expert Group. J Hypertens 2009; 27: 905-922.
TERAPEUTICA
NO FARMACOLOGICA
Each 10-14
mmHg
CHD
DBP
Each 5-6
mmHg
CV Events
Stroke
=
17%
33%
40%
World Health Organization-International Society of Hypertension. The Guidelines Subcommittee of the WHO-ISH. Mild
Hypertension Liaison Committee. 1999 Guidelines for the Management of Hypertension Memorandum.
160
Systolic
Diastolic
140
120
BP
(mm Hg)
100
80
60
40
20
0
Never
(n = 4398)
Ex
(n = 7303)
1-9
(n = 1084)
10-19
(n = 1505)
20+
(n = 1571)
Smoking Categories
Mean of last 2 of 3 automated measurements after 5 min
seated. No food, alcohol, or smoking for >30 min before
measurement.
Non-smokers (n = 8228)
150
100
50
Quintile
0
2
115-120
120-125
130-135
140-225
105-220
1.8
2.5
2.7
2.2
2.5
1.8
1.4-2.3
2.1-3.0
2.0-3.6
1.9-2.7
2.1-2.9
1.3-2.5
1
SBP (mm Hg) 75-115
RR
95% C.I.
Treated Hypertension
25
25
20
15
10
**
20
15
25
******
*
20
15
10
10
Never
(n = 4656)
Previous
(n = 3033)
1-5/d
(n = 454)
11-20/d
6-10/d
(n = 428)
(n = 435)
***
>20/d
(n = 182)
< 0.01, ***P < 0.001 for Adjusted Hazard Ratios vs. Never-Smokers
Adjusted for alcohol consumption, exercise, gender, and age
Reims HM et al. Blood Press 2004;13:376
100
75
%
<25
Men
25 - <27
27 - <30
30+
50
25
0
100
75
20-39
40-59
60+
40-59
60+
Women
50
25
0
20-39
Age (years)
Treated patients
Singh (1990)
Reisin (1978)
Ard
(2000)
Jalkanen (1991)
Lalonde (2002)a
Singh (1995)
Whelton
(1998)
Lalonde
(2002)b
Combined
-30
-20
-10
10
Combined
-20
-10
10
Systolic
2
0
-2
-4
-6
-8
Weight change:
-8.8 kg
-2.6 kg
-0.1 kg
+2.6 kg
+7.3 kg
2
Control Group (n =
554)
0
-2
(mm Hg)
-4
-6
-8
-10
0
12
18
24
30
36
Months
17
P <0.05
142
140
mm Hg
138
136
134
132
130
1-21
>21
76%
Combined
Lang et al, 1995
Cushman et al, 1998
Maheswaran et al, 1992
Ueshima et al, 1987
Ueshima et al, 1993
Rakic et al, 1981
Rakic et al, 1982
Puddey et al, 1985
Kawano et al, 1998
Parker et al, 1990
Puddey et al, 1992
Cox et al, 1993
Puddey et al, 1986
Howes and Reid, 1986
76%
Combined
-15
-10
0
-5
Reduction in blood pressure (mm Hg)
10
There is a dose-response relation between the reduction in blood pressure following a reduction in
alcohol intake.
Xin et al. Hypertension.2001;38:1112-7
ACTIVIDAD FISICA
1.0
0.8
0.6
0.78
0.4
0.62
0.58
0.49
0.44
0.2
0.0
Low
Moderate
Physical Activity
High
25
<25 BMI (kg/m2)
Adjusted for age, area, study year, education, alcohol intake, diabetes at baseline.
Low: Light levels of occupational, commuting (30 minutes), and leisure time physical activity
Moderate: 1 type of moderate-to-high physical activity
Hu G et al. Hypertension 2004;43;25-30
High: 2 - 3 types of moderate-to-high physical activity.
Diastolic
Normotensives
(27 Trials)
0
-1
-2
Changes in
Blood Pressure
(mm Hg)
-3
-4
-5
-6
-7
-8
Whelton SP et al. Ann Intern Med 2002;196:493
0.08
0.06
0.04
HR 0.49 (0.38-0.61)
0.02
0.00
Age 55-80 years
12
24
36
48
60
Months
Fossum E et al. 2006
25
Lancet 1989; ii:1244-7
26
Hypertensive
<140 mmol/d
140-164 mmol/d
>=165 mmol/d
-12
-10
-8
-6
-4
-2
Change in systolic blood pressure (mm Hg)
P <0.0001
Intake
(Portions) 1.0
0.8
Body
Weight
(kg)
0.5
0.0
Systolic
BP
(mm Hg)
NS
0.6
0.4
0.2
0.0
1
Diastolic
BP
(mm Hg)
0
-1
0
-1
P <0.0001
-2
Intervention: Oral and written information and encouragement to
eat five-a-day.
-2
P <0.05
D.A.S.H. diet
132
Control
131
130
129
128
127
126
Combination
125
124
8
7&
ne
123
Ba
se
li
SBP (mmHg)
weeks
N Engl J Med 1997; 336: 1117-1124
3.5
3
-4.6
(-5.9 to 3.2)
132
2.5
130
2
128
1.5
-1.3
(-2.6 to 0.0)
126
-1.7
(-3.0 to 0.4)
124
1
0.5
122
120
-2.1
(-3.4 to 0.8)
134
0
High
Intermediate
Control Diet
Low
DASH Diet
Physical
Activity
Alcohol
Coffee
Sodium
Potassium
Trials (n)
25
49
13
10
40
27
16
36
36
Changea
-6.5 kg
+2.5 h/wk
-41 ml
-4.9 cups
-2.1 g
+2.0 g
+483 mg
+1.2 g
+4.1 g
Magnesium Calcium
Fish oilb
0
-1
-2
-3
-4
Systolic
-5
Diastolic
-6
-7
mm Hg
7.5 mm Hg
5-6 mm Hg
-6
-10
-21
-40
-50
-15
-16
-20
Risk
reduction
(%)
-30
2 mm Hg
-38
CHD
Stroke
-46
CHD, coronary heart disease. Cook NR et al. Arch Intern Med. 1995;155:701-709.
Dyslipidemia
Pharmacological
Treatment
Arterial
Hypertension
Pharmacological
Treatment
Ove
r
Obe weigh
t
s
Pha
i
t
y
rm
a
-Physical
Activity
-Weight Control
-Diet: Na+
colo
gi
Sur cal Tr
e
ger
y atmen
t,
Diabetes
Carbohydrates
-Tobacco,
-Alcohol
-Etc.
Pharmacological
Treatment
CV RISK REDUCTION
Conclusiones
Las modificaciones del estilo de vida son medidas efectivas para la
prevencin y el manejo de la HTA,
Las sugerencias son:
Mantener o llegar, en lo posible, a un peso normal (IMC: 20-25 kg/m2),
Reducir la ingesta de sal a <100 mmol/day (<6g NaCl or <2.4g Na+/day),
Limitar la ingesta de alcohol a <3 unidades/da para varones y a <2 unidades/da para las
mujeres,
Realizar ejercicio aerbico en forma regular (Caminar nadar, bicicleta) >30 min por da,
6 veces por semana, como mnimo,
Consumir, por lo menos, 5 porciones por da de frutas y vegetales frescos,
Reducir la ingesta de grasas totales y saturadas.
PERO FUNDAMENTALMENTE......
INDICACIONES FACTIBLES
TERAPEUTICA
FARMACOLOGICA
Tratamiento
Acebutolol
Amlodipine
Clortalidona
Doxazocina
Enalapril
Todas
Placebo
Varones
-13.2
-13.0
-12.2
-11.7
-11.7
-12.4
-9.1
Mujeres
-12.9
-12.8
-12.5
-11.3
-11.3
-12.2
-7.9
De Waeber B y Brunner, HR. J Hypertens 15(suppl 2): S17-S20; 1997 del Estudio THOMS. Arch Intern Med 156: 377-385; 1996
Respondedores a Monoterapia
Frmaco
Placebo
HCTZ
Atenolol
Cptopril
Diltiazem
Clonidina
Prazosin
n=
187 (138)
188 (108)
178 (80)
188 (110)
185 (88)
178 (84)
188 (80)
Titulacin
33
57
65
56
75
65
56
1 ao
31
55
60
50
72
62
54
Colaterales
6.4
1.1
2.2
4.8
6.5
10.1
13.8
De Waeber B y Brunner, HR. J Hypertens 15(suppl 2): S17-S20; 1997 del NEJM 328: 914-921; 1993 y Am J Hypertens 8: 189-192; 1995
Tratamiento de la HTA
OMS/ISH
Accin Central
Diurticos
IECA
Ca++ Antg
Diurticos
Ca++ Antg
Bloqueantes
IECA
Bloqueantes
IECA
Bloqueantes
Ca Antg
++
Diurticos
Ca++ Antg
Bloqueantes
Bloqueantes
IECA
ARA II
Bloqueantes
B
Diurticos
B
Diurticos
IECA
Ca++ Antg
DIABETES e HTA
TERAPEUTICA
De uso preferencial:
- IECA
- BRA II
- Calcio Antagonistas
SI
- Bloqueantes Beta
Cautela
- De accin central Considerar
- Bloqueantes Alfa
- Diurticos
- Bloqueantes y
Clinical event:
Previous stroke:
Previous MI:
Angina pectoris:
Heart failure diuretics:
Atrial fibrillation:
Recurrent:
Permanent:
ESRD/proteinuria:
Peripheral artery disease:
ARB, ACEI
BB, non-dihydropiridine CA
ACEI, ARB, loop diuretics
CA
Condition:
ISH (elderly):
Metabolic syndrome:
Diabetes mellitus:
Pregnancy:
Blacks:
Diuretics, CA
ACEI, ARB, CA
ACEI, ARB
CA, methyldopa, BB
Diuretics, CA
Ms de 1 Frmaco Antihipertensivo
se requiere para el control de la HTA
Trial
1
UKPDS 1
DBP < 85
ABCD 2
DBP < 75
MDRD 3
MAP < 92
HOT 4
DBP < 80
AASK 5
MAP < 92
IDNT 6
DBP - Diastolic Blood Pressure; MAP - Mean Arterial Pressure; SBP -Systolic Blood Pressure
161/98
144/85
Final
68%
68%
< 85
mmHg
142/83
74%
< 80
mmHg
140/81
142/83
Combinacin
Monoterapia
Hanson L et al. Lancet 1998; 351: 1755-1762
< 90 mmHg
Combinar antihipertensivos?
Moda o necesidad?
Siglo XXI:
-ARAII con Ca++ Antg
-ARA II con Ca++ Antg y Estatina
Modificado de Epstein M and Bakris G. Arch Int Med 156: 1969-1978; 1996
SINERGIA
Diurticos
Beta bloqueantes
Antagonista
Receptores de
Angiotensina II
Alfa bloqueantes
Antagonistas
Canales de Calcio
IECAs
Las familias de drogas que estn recuadrados han sido probados en estudios CONTROLADOS
Fuente: Guas para el Tratamiento de la Hipertensin Arterial. Sociedad Europea de HTA / Cardiologa 2003.
Asociaciones o Combinaciones
-Sabemos que solo 1/3 de la poblacin de hipertensos responde
a la Monoterapia,
-Segn el riesgo agregado, el objetivo terapetico es MAYOR,
-Las asociaciones y combinaciones son eficaces y acortan LOS
TIEMPOS en la reduccin de la PA,
-Que SIEMPRE hemos usado asociaciones o combinaciones.
POR LO TANTO:
CUANDO LAS USAMOS?
Tratamiento Farmacolgico.
2003 European Society of Hypertension European Society of Cardiology Guidelines for the Management of Arterial Hypertension, J Hypertens, 2003
Considerar :
Nivel de PA previo al tratamiento Ausencia o Presencia de DOB y FR.
Elegir entre:
Elevacin leve de PA
Elevacin marcada de PA
Riesgo CV: L a M
Objetivo PA convencional
Monodroga en
baja dsis
Combinacin de 2 Frmacos a
baja dsis
Aumentar a
Cambiar a otro
dsis mxima frmaco en dsis baja
Subir a dsis
mxima
Agregar un 3er
frmaco a bajas dsis
Asociacin de
2-3 frmacos
Terapia a
dsis mxima
Aumento de Riesgo CV
Condiciones Asociadas
Microalbuminuria
Hypercoagulabilidad
Obesidad Visceral
DBT Tipo 2
Riesgo CV
Fumar
Hipertensin
Insulino Resistencia
Dislipemia
Sobrepeso
Obesidad
INTERHEART:MultipleRiskFactors.
ImpactonCVRisk
512
2.9
2.4
1.9
3.3
13.0
42.3
68.5
182.9
333.7
256
128
Tasa de
Probab.
del
1*IMA
64
(99% IC)
32
16
20 veces
de riesgo
4
2
1
Tabaco
(1)
52 pases
12,461casos
12,467 controles
DM
(2)
HTA
(3)
ApoB- 1+2+3
ApoA1
(4)
Los 4
Los 4
Los 4
+ Obes + Estres
Todos
los F.R
0
-5
-10
Treatment
Based on TC
(statin)
-6
-9
-15
Treatment
Based on BP
(-blocker,
diuretic)
-6
-12
-8
Treatment Based on
Overall Absolute Risk
(ASA, statin, ACEI,
-blocker, diuretic)
-10
-17
-20
-25
-30
-35
-40
Treatment thresholds
Top 10%
Top 20%
Top 30%
Adapted from Emberson et al. Eur Heart J. 2004;25:484-491.
-28
-37
PolyPill
The concept of a polypill was born in 2003, when British professors from the Wolfson
Institute of Preventive Medicine in London, UK, Nick J Wald and Malcolm R Law,
proposed a polypill containing six constituents in the BMJ [Wald NJ and Law MR. A strategy to reduce cardiovascular
disease by more than 80%. BMJ 2003; 326:1419.].
They settled on a hypothetical pill combining a statin; three blood-pressure-lowering
drugs, each at a half-standard dose (potentially a thiazide, beta blocker, and ACE
inhibitor); 0.8-mg folic acid; and 75-mg aspirin. Such a product could slash the risk of
cardiovascular events by 80% or more and benefit one in three people if everyone over the
age of 55 were to take the pill, they calculated. And by including only half-doses of the
antihypertensives, the risk of adverse effects would be minimized, they said.
Version of
polypill
Aspirin
Lisinopril
Simvastati HCTZ
n
(mg)
(mg)
(mg)
(mg)
Low-dose
75
10
12.5
Mediumdose
75
10
20
12.5
High-dose
75
10
40
12.5
PolyPill
January 19, 2007 (Hyderabad, India) . Just three and a half years on from the first
proposal for a polypill, an Indian company has begun clinical trials of such a product,
containing aspirin, lisinopril, simvastatin, and atenolol, in 250 Indian patients who have
already had a cardiovascular event.
Raghu Cidambi (Dr Reddy's Laboratories, Hyderabad, India) told heartwire the company
hopes to gain Indian approval of this version of the polypill for secondary prevention on the
basis of this trial, which has already completed enrollment.
"We believe that we don't need an elaborate outcomes trial for secondary prevention," he
said. "It is our understanding that as long as there is solid evidence of no drug-drug
interaction and that the pill achieves its goals of reducing blood pressure and cholesterol,
it will be approved.
Smoking
Diet
Sedentary lifestyle
Alcohol/drug abuse
Obesity
CAD
Atrial fibrillation
Hypertension
Diabetes
Dyslipidemia
Age
Male sex
Race
Family history of
stroke/TIA
Prior stroke/TIA
Aspirin dose
(mg)
Lisinopril dose
(mg)
Simvastatin
dose (mg)
Atenolol dose
(mg)
Low-Dose
75
10
25
Medium-Dose
75
10
20
50
High-Dose
75
10
40
50
CONSTITUENTS OF PRIMARY-PREVENTION
POLYPILL
Version of
Polypill
Aspirin dose
(mg)
Lisinopril dose
(mg)
Simvastatin
dose (mg)
Hydrochlorothiazide
(mg)
Low-Dose
75
10
12.5
Medium-Dose
75
10
20
12.5
High-Dose
75
10
40
12.5
Wald NJ and Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ 2003; 326:1419.