truong quang binh khoi tri

4 Systolic BP: highly predictive of stroke risk Stroke mortality* * Floating absolute risk and 95% confidence interval.. SBP, systolic blood pressure... 1,991 CAD patients ≥ 20%; doubl

KHỞI TRỊ TĂNG HA Ở

NGƯỜI CAO TUỔI:

CHỨNG CỨ LIÊN QUAN ĐẾN THUỐC LỢI TiỂU

PGS TS Trương Quang Bình

ĐHYD TP HCM

4

Systolic BP:

highly predictive of stroke risk

Stroke mortality*

* Floating absolute risk and 95% confidence interval

SBP, systolic blood pressure

1 Lewington S et al Lancet 2002;360:1903-1913

Age at risk

80-89 y 70-79 y 60-69 y 50-59

Hypertension sub-type According to Age

Franklin SS, et al Circulation 1997;96: 308-15

6

Reflected waves due to stiffer arteries from periphery

increase pulse wave velocity & Systolic BP

1 O’Rourke M Hypertension 1995;26:2-9

7

Older patients have a low level of renin activity

1 Belmin et al Drugs Aging 1994;5(5):391-400

Supine plasma renin activity (PRA) and aldosterone plasma level

as a function of age in healthy normotensive people receiving an ad libitum sodium diet

Tieán trieån cuûa taêng HA

B Williams 2007 Number

Amlodipine has Shown CV Protective Efficacy in

Landmark Studies

1 Pitt et al Circulation 2000;102:1503–1510; 2 Nissen et al JAMA 2004;292:2217–2226; 3 Dahlof et al Lancet

2005;366:895–906; 4 Williams et al Circulation 2006;113:1213 –1225; 5 Leenen et al Hypertension.2006;48:374–384

1,991 CAD patients (≥ 20%); double-blind,

randomized study vs placebo and enalapril

randomized, prospective study vs atenolol

Primary outcome: 10%↓in non-fatal MI and fatal CHD

randomized, prospective study vs lisinopril

Primary outcome: no difference in composite of fatal CHD and non-fatal MI vs lisinopril

23% ↓stroke

A = ACE-inh or ARB, C = CCB, D = thiazide type diuretic

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ALLHAT

Chlorthalidone Amlodipine Lisinopril

Cumulative Event Rates for Heart Failure

by ALLHAT Treatment Group

HR (95% CI) p value A/C 1.38 (1.25-1.52) <.001 L/C 1.19 (1.07-1.31) <.001

ALLHAT

Chlorthalidone Amlodipine Lisinopril

Number at risk:

Chlor 15,255 14,528 13,898 13,224 11,511 6,369 3,016 384

Amlo 9,048 8,535 8,185 7,801 6,785 3,775 1,780 210

Lisin 9,054 8,496 8,096 7,689 6,698 3,789 1,837 313

HYVET Trial: Study Design

causes, cardiac causes and any cause

Active Treatment 1.5 mg Indapamide (SR)

n=1933

Placebo Matching Dose

n=1912

3845 patients > 80 years with continual hypertension and systolic blood pressure ≥

160 mm Hg prior to randomization Prospective Randomized Double Blind Placebo-Controlled Mean follow-up 1.8yrs

N Engl J Med 2008;358/ACC 2008

R

2 yrs follow-up

ESH/ESC guidelines suggest a diuretic or a CCB may be

particularly useful for elderly patients

19

Thiazide diuretics / CCB combination is recommended

for older hypertensive patients

JNC8 panel report recommends a CCB or a thiazide-type diuretic, alone or in combination for patients over 60

20

Thiazide diuretics / CCB combination is recommended

for older and black hypertensive patients

James PA et al JAMA 2014;311(5):507-520

21

2015

Hypertension Canada CHEP Guidelines for the Management of Hypertension

2016

Indapamide is more potent than HCTZ & chlorthalidone

at reducing systolic blood pressure

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Roush et al Hypertension 2015;65:1041-1046

Indapamide is significantly more potent than HCTZ at reducing systolic blood

pressure, which is not the case with chlorthalidone

Roush meta-analysis (2015) 1

Systematic review and meta-analysis; head-to- head RCTs comparing HCTZ vs indapamide (10 RCTS, n=813) and HCTZ

vs chlorthalidone (3 RCTS, n=70)

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Indapamide has a better metabolic profile…

1 Ambrosioni E, Safar M, Degaute JP, et al J Hypertens 1998;16:1677-1684; 2 ALLHAT Collaborative Research Group JAMA 2002;288:2981-2997

• Above age 50, systolic BP management becomes

more important

• High SBP is linked to stroke risk & is difficult to

control

• Thiazide-like diuretics & CCBs are logical choice

for treatment of high SBP

• Among thiazide-like diuretics, indapamide has

better metabolic safety

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In summary