SPRINT trial: quoi de neuf en hypertension ? Approche pratique du - - PowerPoint PPT Presentation
SPRINT trial: quoi de neuf en hypertension ? Approche pratique du patient cardiaque en mdecine 17 me dition du Congrs de la Ligue Cardiologique Belge 21 mai 2016 gnrale Philippe van de Borne Service de Cardiologie ULB
The SPRINT Research Group
N Engl J Med Volume 373(22):2103-2116 November 26, 2015
Patients at increased cardiovascular risk but without diabetes: target systolic BP <120 mm Hg (intensive) or <140 mm Hg (standard).
The protocol encouraged the use of drug classes with the strongest evidence for reduction in cardiovascular outcomes
The SPRINT Research Group. N Engl J Med 2015;373:2103-2116
Composite
infarction, acute coronary syndrome, stroke, heart failure,
death from cardiovascular causes
?
Blood pressure in mm Hg ¡ NICE 2011[2] ¡ ESH/ESC 2013[3] ¡ ASH/ISH 2014 [4] ¡ Go A. et al. AHA/ ACC/CDC 2013 [5] ¡ 2014 Hypertension guidelines, US “JNC 8” [6] ¡
Definition of Hypertension ¡
≥140/90 and daytime ABPM (or home BP) ≥135/85 ¡ ≥140/90 ¡ ≥140/90 ¡ ≥140/90 ¡ Not addressed ¡
Drug therapy in low risk patients after non- pharmacologic treatment ¡
≥160/100
day-time ABPM ≥ 150/95 ¡ ≥140/90 ¡ ≥140/90 ¡ ≥140/90 ¡ < 60 y. ≥140/90 ≥ 60 y. ≥150/90 ¡
Beta-blockers as first line drug ¡
No (Step 4) ¡ Yes ¡ No (Step 4) ¡ No (Step 3) ¡ No (Step 4) ¡
Diuretic ¡
chlorthalidone, indapamide ¡ thiazides chlorthalidone, indapamide ¡ thiazides chlorthalidone indapamide ¡ thiazides ¡ thiazides chlorthalidone, indapamide ¡
Initiate drug therapy with two drugs ¡
Not mentioned ¡ In patients with markedly elevated BP ¡ ≥160/100 ¡ ≥160/100 ¡ ≥160/100 ¡
Blood pressure targets ¡
< 140/90 ≥ 80 y. < 150/90 ¡ <140/90 Elderly < 80 y. SBP 140-150 SBP <140 in fit patients Elderly ≥ 80 y. SBP 140-150 ¡ <140/90 ≥ 80 y. < 150/90 ¡ <140/90 Lower targets may be appropriate in some patients, including the elderly ¡ < 60 y. <140/90 ≥ 60 y. <150/90 ¡
Blood Pressure target in patients with diabetes mellitus ¡
Not addressed ¡ < 140/85 ¡ <140/90 ¡ <140/90 Lower targets may be considered ¡ <140 /90 ¡
Lindholm LH, Carlberg B. HT News 2014, Opus 35
Blood pressure in mm Hg ¡ NICE 2011[2] ¡ ESH/ESC 2013[3] ¡ ASH/ISH 2014 [4] ¡ Go A. et al. AHA/ ACC/CDC 2013 [5] ¡ 2014 Hypertension guidelines, US “JNC 8” [6] ¡
Definition of Hypertension ¡
≥140/90 and daytime ABPM (or home BP) ≥135/85 ¡ ≥140/90 ¡ ≥140/90 ¡ ≥140/90 ¡ Not addressed ¡
Drug therapy in low risk patients after non- pharmacologic treatment ¡
≥160/100
day-time ABPM ≥ 150/95 ¡ ≥140/90 ¡ ≥140/90 ¡ ≥140/90 ¡ < 60 y. ≥140/90 ≥ 60 y. ≥150/90 ¡
Beta-blockers as first line drug ¡
No (Step 4) ¡ Yes ¡ No (Step 4) ¡ No (Step 3) ¡ No (Step 4) ¡
Diuretic ¡
chlorthalidone, indapamide ¡ thiazides chlorthalidone, indapamide ¡ thiazides chlorthalidone indapamide ¡ thiazides ¡ thiazides chlorthalidone, indapamide ¡
Initiate drug therapy with two drugs ¡
Not mentioned ¡ In patients with markedly elevated BP ¡ ≥160/100 ¡ ≥160/100 ¡ ≥160/100 ¡
Blood pressure targets ¡
< 140/90 ≥ 80 y. < 150/90 ¡ <140/90 Elderly < 80 y. SBP 140-150 SBP <140 in fit patients Elderly ≥ 80 y. SBP 140-150 ¡ <140/90 ≥ 80 y. < 150/90 ¡ <140/90 Lower targets may be appropriate in some patients, including the elderly ¡ < 60 y. <140/90 ≥ 60 y. <150/90 ¡
Blood Pressure target in patients with diabetes mellitus ¡
Not addressed ¡ < 140/85 ¡ <140/90 ¡ <140/90 Lower targets may be considered ¡ <140 /90 ¡
Lindholm LH, Carlberg B. HT News 2014, Opus 35
Maciej Banach & Wilbert S. Aronow
Curr Hypertens Rep (2012) 14:556–566
Overall, it means that the lower treatment arm in SPRINT translates into SBP <136 mm Hg, which is not very different from SBP <140 mm Hg, which is the currently recommended SBP target by all guidelines.
The BP measurement technique in SPRINT is different from ACCORD, SPS3, and HOT, since other people were out of the room during measurements and the entire resting period before measurement.
HOPE-3 published on April 2, 2016, at NEJM.org. composite of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke
We identified 123 studies with 613 815 participants for the tabular meta-analysis...
Coronary blood flow in normotensive patients (white circles), hypertensive patients without left ventricular hypertrophy (squares) and hypertensive patients with left ventricular hypertrophy (black circles).
Polese A, De Cesare N, Montorsi P, Fabbiocchi F, Guazzi M, Loaldi A, Guazzi MD. Upward shift of the lower range of coronary flow autoregulation in hypertensive patients with hypertrophy of the left ventricle. Circulation. 1991;83:845– 853.