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 2018 ESC-ESH Guidelines for the Management of Arterial Hypertension 28 th ESH Meeting on Hypertension and Cardiovascular protection Barcelona June 2018 NOUVEAU !!!! Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

2018 ESC/ESH Hypertension Guidelines Treatment of CV risk factors associated with hypertension Recommendations Class Level CV risk assessment with the SCORE system is recommended for I B hypertensive patients who are not already at high or very risk due to established CVD, renal disease, or diabetes. For patients at very high CV risk , statins are recommended to I B 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). For patients at high CV risk , statins are recommended to achieve an I B 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). For patients at low to moderate CV risk, statins should be considered, IIa C to achieve an LDL-C value of < 3.0 mmol/L (115 mg/dL). Antiplatelet therapy, in particular low-dose aspirin, is recommended for I A secondary prevention in hypertensive patients. Aspirin is not recommended for primary prevention in hypertensive III A patients without CVD. Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

2018 ESC/ESH Hypertension Guidelines 10-year CV risk categories (SCORE system) 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 other arterial revascularization, stroke, TIA, aortic aneurysm, PAD. • Unequivocal documented CVD on imaging includes: significant plaque (i.e. ≥ 50% Very high risk stenosis) on angiography or ultrasound. It does not include increase in carotid intima-media <70 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 m 2 ) A calculated 10-year SCORE of ≥ 10% 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 <100 High risk mellitus and without major risk factors, that may be moderate risk) Hypertensive LVH Moderate CKD eGFR 30–59 mL/min/1.73 m 2 ) A calculated 10-year SCORE of 5–10% People with: A calculated 10-year SCORE of 1% to < 5% <115 Moderate risk Grade 2 hypertension Many middle-aged people belong to this category People with: Low risk A calculated 10-year SCORE of < 1% Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

2018 ESC/ESH Hypertension Guidelines Classification of hypertension stages according to BP levels, presence of CV risk factors, HMOD, or comorbidities BP (mmHg) grading Hypertension Other risk factors, High-normal Grade 1 Grade 2 Grade 3 disease HMOD, or disease SBP 130 − 139 SBP 140 − 159 SBP 160 − 179 SBP ≥ 180 staging DBP 85 − 89 DBP 90 − 99 DBP 100 − 109 DBP ≥ 110 No other risk factors Low risk Low risk Moderate risk High risk Moderate − Stage 1 1 or 2 risk factors Low risk Moderate risk High risk (uncomplicated) high risk Low –moderate Moderate − ≥ 3 risk factors High risk High risk risk high risk HMOD, CKD grade 3, or Stage 2 Moderate − High – very diabetes mellitus High risk High risk (asymptomatic high risk high risk disease) without organ damage Established CVD, CKD grade ≥ 4, or diabetes Stage 3 Very high risk Very high risk Very high risk Very high risk mellitus with organ damage Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

2018 ESC/ESH Hypertension Guidelines And no : HMOD, CKD grade ≥ 3, or diabetes mellitus without/with organ damage, established CVD Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

2018 ESC/ESH Hypertension Guidelines 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 NONE OF THOSE !!! Echocardiographic LVH Microalbuminuria or elevated albumin–creatinine ratio Moderate CKD with eGFR > 30–59 mL/min/1.73 m 2 (BSA) or severe CKD eGFR < 30 mL/min/1.73 m 2 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 Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

2018 ESC/ESH Hypertension Guidelines Factors influencing CV risk in patients with hypertension - 1 Demographic characteristics and laboratory parameters Sex (men > women) IF Age SBP < 139 mmHg Smoking – current or past history DBP < 89 mmHg Total cholesterol and HDL-C (but < 310 mg/dL) Uric acid THEN MAXIMUM 2 OUT OF THIS LIST 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) + NO Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

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

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

Types of CV Outcomes Evolocuma Placebo b (N=13,780) Endpoint HR (95% CI) (N=13,784) 3-yr Kaplan-Meier rate CV death, MI, or stroke 7.9 9.9 0.80 (0.73-0.88) No effect 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 -2% 6.3 0.73 (0.65-0.82) -0,5% Stroke 2.2 2.6 0.79 (0.66-0.95) Overall, 74 patients would need to be treated over a period of 2 years to prevent a cardiovascular death, myocardial infarction, or stroke. An Academic Research Organization of Brigham and Women’s Hospital and Harvard Medical School

ACC.18 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 Randomiza>on Placebo SC Q2W Alirocumab SC Q2W Pa;ent and inves;gators remained blinded to treatment and lipid levels for the en;re dura;on of the study Schwartz GG, et al. Am Heart J 2014;168:682-689.e1. 16

ACC.18 A Target Range for LDL-C Undesirably high Target baseline range range We aZempted to maximize the number of Acceptable range pa;ents in the target Below target range and minimize the number below target by blindly ;tra;ng Alirocumab alirocumab (75 or 150 mg SC Q2W) or blindly switching to placebo. 0 15 25 50 70 LDL-C (mg/dL) Schwartz GG, et al. Am Heart J 2014;168:682-689.e1. 17

ACC.18 Main Secondary Efficacy Endpoints: Hierarchical Tes;ng *Nominal P-value 18

2018 ESC/ESH Hypertension Guidelines Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press

TNF- α , tumour necrosis factor-alpha; IL-6, interleukin-6; PAI-1, plasminogen activator inhibitor type-1; SAA, serum amyloid A From: Peter Libby MD and CANTOS Eur Heart J. 2018;39(17):1504-1505. doi:10.1093/eurheartj/ehy177

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, or Cardiovascular Death

2018 ESC/ESH Hypertension Guidelines MERCI POUR VOTRE ATTENTION ! Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press