3*25 min et surtout qui nest PAS risque ? 2018 ESC/ESH - - PowerPoint PPT Presentation

3*25 min

… et surtout qui n’est PAS à risque ?

2018 ESC/ESH Hypertension Guidelines

Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

2018 ESC-ESH Guidelines for the Management of Arterial Hypertension

28th ESH Meeting on Hypertension and Cardiovascular protection Barcelona June 2018

NOUVEAU !!!!

2018 ESC/ESH Hypertension Guidelines

Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

Treatment of CV risk factors associated with hypertension

Recommendations Class Level CV risk assessment with the SCORE system is recommended for hypertensive patients who are not already at high or very risk due to established CVD, renal disease, or diabetes. I B For patients at very high CV risk, statins are recommended to achieve LDL-C levels of < 1.8 mmol/L (70 mg/dL), or a reduction of ≥ 50% if the baseline LDL-C is 1.8–3.5 mmol/L (70–135 mg/dL). I B For patients at high CV risk, statins are recommended to achieve an LDL-C goal of < 2.6 mmol/L (100 mg/dL) or a reduction of ≥ 50% if the baseline LDL-C is 2.6–5.2 mmol/L (100–200 mg/dL). I B For patients at low to moderate CV risk, statins should be considered, to achieve an LDL-C value of < 3.0 mmol/L (115 mg/dL). IIa C Antiplatelet therapy, in particular low-dose aspirin, is recommended for secondary prevention in hypertensive patients. I A Aspirin is not recommended for primary prevention in hypertensive patients without CVD. III A

2018 ESC/ESH Hypertension Guidelines

Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

10-year CV risk categories (SCORE system)

Very high risk People with any of the following: Documented CVD, either clinical or unequivocal on imaging.

• Clinical CVD includes; acute myocardial infarction, acute coronary syndrome, coronary or
• ther arterial revascularization, stroke, TIA, aortic aneurysm, PAD.
• Unequivocal documented CVD on imaging includes: significant plaque (i.e. ≥ 50%

stenosis) on angiography or ultrasound. It does not include increase in carotid intima-media thickness. Diabetes mellitus with target organ damage, e.g. proteinuria or a with a major risk factor such as grade 3 hypertension or hypercholesterolaemia Severe CKD (eGFR < 30 mL/min/1.73 m2) A calculated 10-year SCORE of ≥ 10% High risk People with any of the following: Marked elevation of a single risk factor, particularly cholesterol > 8 mmol/L (> 310 mg/dL) e.g. familial hypercholesterolaemia, grade 3 hypertension (BP ≥ 180/110 mmHg) Most other people with diabetes mellitus (except some young people with type 1 diabetes mellitus and without major risk factors, that may be moderate risk) Hypertensive LVH Moderate CKD eGFR 30–59 mL/min/1.73 m2) A calculated 10-year SCORE of 5–10% Moderate risk People with: A calculated 10-year SCORE of 1% to < 5% Grade 2 hypertension Many middle-aged people belong to this category Low risk People with: A calculated 10-year SCORE of < 1%

<70 <100 <115

2018 ESC/ESH Hypertension Guidelines

Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

Classification of hypertension stages according to BP levels, presence of CV risk factors, HMOD, or comorbidities

Hypertension disease staging Other risk factors, HMOD, or disease BP (mmHg) grading High-normal SBP 130−139 DBP 85−89 Grade 1 SBP 140−159 DBP 90−99 Grade 2 SBP 160−179 DBP 100−109 Grade 3 SBP ≥ 180 DBP ≥ 110 Stage 1

(uncomplicated)

No other risk factors Low risk Low risk Moderate risk High risk 1 or 2 risk factors Low risk Moderate risk Moderate − high risk High risk ≥ 3 risk factors Low –moderate risk Moderate − high risk High risk High risk Stage 2

(asymptomatic disease)

HMOD, CKD grade 3, or diabetes mellitus without organ damage Moderate − high risk High risk High risk High – very high risk Stage 3 Established CVD, CKD grade ≥ 4, or diabetes mellitus with organ damage Very high risk Very high risk Very high risk Very high risk

2018 ESC/ESH Hypertension Guidelines

Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

And no : HMOD, CKD grade ≥ 3, or diabetes mellitus without/with organ damage, established CVD

2018 ESC/ESH Hypertension Guidelines

Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

Factors influencing CV risk in patients with hypertension - 2

Asymptomatic HMOD Arterial stiffening: Pulse pressure (in older people) ≥ 60 mmHg Carotid–femoral PWV > 10 m/s ECG LVH Echocardiographic LVH Microalbuminuria or elevated albumin–creatinine ratio Moderate CKD with eGFR > 30–59 mL/min/1.73 m2 (BSA) or severe CKD eGFR < 30 mL/min/1.73 m2 Ankle−brachial index < 0.9 Advanced retinopathy: haemorrhages or exudates, papilloedema Established CV or renal disease Cerebrovascular disease: ischaemic stroke, cerebral haemorrhage, TIA CAD: myocardial infarction, angina, myocardial revascularization Presence of atheromatous plaque on imaging Heart failure, including HFpEF Peripheral artery disease Atrial fibrillation

NONE OF THOSE !!!

2018 ESC/ESH Hypertension Guidelines

Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

Factors influencing CV risk in patients with hypertension - 1

Demographic characteristics and laboratory parameters Sex (men > women) Age Smoking – current or past history Total cholesterol and HDL-C Uric acid Diabetes (except some young people with type 1 diabetes mellitus) Overweight or obesity Family history of premature CVD (men aged < 55 years and women aged < 65 years) Family or parental history of early onset hypertension Early onset menopause Sedentary lifestyle Psychosocial and socioeconomic factors Heart rate (resting values > 80 beats per min)

IF SBP < 139 mmHg DBP < 89 mmHg THEN MAXIMUM 2 OUT OF THIS LIST + NO (but < 310 mg/dL)

2018 ESC/ESH Hypertension Guidelines

Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

REDUCTION MAXIMALE DE 60%

Clinical Therapeutics Volume 35, Issue 8, August 2013, Pages 1082–1098

revascularisation PRIMAIRE : DECES CARDIOVASCULAIRES, INFARCTUS MYOCARDIAQUE, HOSPITALISATION POUR ANGINE DE POITRINE INSTABLE OU REVASCULARISATION CORONAIRE SECONDAIRE : DECES CARDIOVASCULAIRES, INFARCTUS MYOCARDIQUE, ACCIDENT CEREBROVASCULAIRE

An Academic Research Organization of Brigham and Women’s Hospital and Harvard Medical School

Types of CV Outcomes

Endpoint Evolocuma b (N=13,784) Placebo (N=13,780) HR (95% CI)

3-yr Kaplan-Meier rate

CV death, MI, or stroke 7.9 9.9 0.80 (0.73-0.88) Cardiovascular death 2.5 2.4 1.05 (0.88-1.25) Death due to acute MI 0.26 0.32 0.84 (0.49-1.42) Death due to stroke 0.29 0.30 0.94 (0.58-1.54) Other CV death 1.9 1.8 1.10 (0.90-1.35) MI 4.4 6.3 0.73 (0.65-0.82) Stroke 2.2 2.6 0.79 (0.66-0.95)

• 2%
• 0,5%

No effect Overall, 74 patients would need to be treated over a period of 2 years to prevent a cardiovascular death, myocardial infarction, or stroke.

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Treatment Assignment

Post-ACS pa;ents (1 to 12 months) Run-in period of 2−16 weeks on high-intensity or maximum-tolerated dose of atorvasta;n or rosuvasta;n At least one lipid entry criterion met

Placebo SC Q2W Alirocumab SC Q2W

Randomiza>on Schwartz GG, et al. Am Heart J 2014;168:682-689.e1.

Pa;ent and inves;gators remained blinded to treatment and lipid levels for the en;re dura;on of the study

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Undesirably high baseline range LDL-C (mg/dL) Target range Alirocumab Below target 70 50 25 15 Acceptable range

A Target Range for LDL-C

Schwartz GG, et al. Am Heart J 2014;168:682-689.e1.

We aZempted to maximize the number of pa;ents in the target range and minimize the number below target by blindly ;tra;ng alirocumab (75 or 150 mg SC Q2W) or blindly switching to placebo.

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Main Secondary Efficacy Endpoints:

Hierarchical Tes;ng

*Nominal P-value

2018 ESC/ESH Hypertension Guidelines

Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

From: Peter Libby MD and CANTOS Eur Heart J. 2018;39(17):1504-1505. doi:10.1093/eurheartj/ehy177

TNF-α, tumour necrosis factor-alpha; IL-6, interleukin-6; PAI-1, plasminogen activator inhibitor type-1; SAA, serum amyloid A

Hazard ratios for incident CV events in the JUPITER trial according to achieved concentrations of LDL-C and Hs-CRP after initiation of rosuvastatin therapy. History of myocardial infarction and had a blood level of Hs-CRP > 2 mg/L despite the use of aggressive secondary prevention strategies.

Nonfatal myocardial infarction, Nonfatal stroke,

• r Cardiovascular Death

2018 ESC/ESH Hypertension Guidelines

Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

MERCI POUR VOTRE ATTENTION !