高血压英文ppt精品课件hypertension and the _1

Hypertension and The Heart Vasilios Papademetriou, MD Professor of Medicine (Cardiology) Georgetown University Director Hypertension and Cardiovascular Research VAMC Washington DC FDRs Final Picture (April 11, 1945) FDRs BP as recorded April 1944 at Bethesda Naval Hospital CV Complications of Untreated Hypertension (N=500) 2 0 5 10 15 20 25 30 35 40 45 50 18 12 8 16 50 Renal Failure Stroke Enceph MI Angina CHF MI, myocardial infarction; CHF, chronic heart failure. Perera GA J. Chron Dis. 1955;1:33-42. Event rate (%) LVH, left ventricular hypertrophy; MI, myocardial infarction; CHF, chronic heart failure. Vasan RS and Levy D. Arch Intern Med. 1996;156:1789-1796. Progression From Hypertension to Heart Failure Hypertension Smoking Dyslipidemia Diabetes Obesity Diabetes MI LVH CHF Normal LV Structure and Function LV Remodeling Subclinical LV Dysfunction Overt Heart Failure Diastolic Dysfunction Systolic Dysfunction Cumulative Incidence (%) Cumulative Incidence (%) Cumulative Incidence of Heart Failure by Baseline Hypertension Status Time (y) Stage 1 25 20 15 10 5 0 2 4 6 8 10 12 14 16 Stage 2+ Men aged 60-69 y Normotensive 2 4 6 8 10 12 14 Men aged 70-79 y Stage 2+ Stage 1 Normotensive 40 30 20 10 0 Levy D et al. JAMA. 1996;275:1557-1562. 25 20 15 10 5 0 2 4 6 8 10 12 14 16 Stage 2+ Stage 1 Women aged 60-69 y Normotensive Stage 1 Normotensive Stage 2+ 40 30 20 10 0 2 4 6 8 10 12 14 Women aged 70-79 y Population-attributable risk defined as: (100 x prevalence x hazard ratio 1)/(prevalence x hazard ratio 1 + 1) Population-Attributable Risks for Development of CHF CHF, chronic heart failure; AP, angina pectoris; DM, diabetes mellitus; LVH, left ventricular hypertrophy; VHD, valvular heart disease; HTN, hypertension; MI, myocardial infarction. Levy D et al. JAMA. 1996;275:1557-1562. AP 5%DM 6% LVH 4% VHD 7% MI 34% HTN 39% Men Women HTN 59% DM 12% LVH 5% VH D 8% AP 5% MI 12% Effects of Hypertension on The Heart l Left Ventricular Hypertrophy l Vascular Disease: -Atherosclerosis -Arteriosclerosis Prevalence of Systolic and Diastolic Dysfunction by Age Redfield MM et al. JAMA. 2003;289:194-202. % of Population 0 10 20 30 40 50 EF75 ALL 60 SYSTOLIC AND DIASTOLIC HEART FAILURE lLOW EF l HIGH LV MASS l MYOCYTE HYPERTOPHY l INTERSTITIAL FIBROSIS l ABNORM CALC HANDLING l REDUCED CONTRACTILITY l SLOWED RELAXATION l DEPLETED PREL0AD RESERVE l LARGE VOLUMES lNORMAL EF l HIGH LV MASS l MYOCYTE HYPERTROPHY l INTERSTITIAL FIBROSIS l ABNORM CALC HANDLING l REDUCED CONTRACTILITY l SLOWED RELAXATION l DEPLETED PRELOAD RESERVE l SMALL VOLUMES KONSTAM MA; J OF CARDIAC FAILURE, 2003 VOL 9, No 1; 1-3. Left Ventricular Hypertrophy Independent Predictor of: l Myocardial infarction l Stroke l Heart Failure l Total Mortality l Sudden Death *Other antihypertensives excluding ACEIs, AII antagonists, beta-blockers. Dahlf B et al Am J Hypertens 1997;10:705713. LIFE: Design Dosing Day 14 Day 7 Day 1 Mth 1 Mth 2 Mth 4 Mth 6 Yr 1 Yr 1.5 Yr 2 Yr 2.5 Yr 3 Yr 3.5 Yr 4 Yr 5 Titration to target blood pressure: 40% ACE inhibitor treated/not treated Primary outcome for Overall Programme: All-cause death Primary outcome for each trial: CV death or CHF hospitalisation 33* CHARM-Preserved Primary and secondary outcomes CV death, CHF hosp. 333 366 - CV death 170 170 - CHF hosp. 241 276 CV death, CHF hosp, 365 399 MI CV death,CHF hosp, 388 429 MI, stroke CV death,CHF hosp, 460 497 MI, stroke, revasc candesartan better Hazard ratio placebo better 0.8 1.0 1.2 p-value 0.918 0.072 0.118 0.126 0.078 0.123 Covariate adjusted p-value 0.635 0.047 0.051 0.051 0.037 0.13 Candesartan Placebo 0.89 0.99 0.85 0.90 0.88 0.91 Effects of Hypertension on The Heart Left Ventricular Hypertrophy Vascular Disease: -Atherosclerosis -Arteriosclerosis ATHERO- ARTERIO- SCLEROSIS SCLEROSIS (Increased vascular stiffness Decreased vascular compliance) Focal, Occlusive Inflammatory Endothelial dysfunction Related to LDL cholesterol oxidation “Inside-out” Sensitive to A II and other substances Diffuse, Dilatory Fibrotic (elastin breakdown, collagen increase) Adventitial and medial hypertrophy Related to age and BP “Outside-in” Sensitive to A II and other substances 36 Integrated Perspective on CV Risk Factors and Vascular Disease CV Disease Ross. N Engl J Med. 1999;340:115-126. Oxidative Stress 340:115-126. Ross R, N Engl J Med 340 (1999) n=347,978 men without previous myocardial infarction. Neaton JD et al. In: Hypertension: Pathophysiology, Diagnosis, and Management. 1995:127-144. SBP (mm Hg) = 65 1.33 (1.18, 1.49) Age = 65 1.20 (1.06, 1.35) Age 65 1.23 (1.01, 1.50) Total 1.20 (1.09, 1.34) BP Results by Treatment Group Compared to chlorthalidone: SBP significantly higher in the amlodipine group (1 mm Hg) and the lisinopril group (2 mm Hg). ALLHAT 130 135 140 145 150 0 1 2 3 4 5 6 Years BP (mmHg) Chlorthalidone Amlodipine Lisinopril Compared to chlorthalidone: DBP significantly lower in the amlodipine group (1 mm Hg). 70 75 80 85 90 0 1 2 3 4 5 6 Years BP (mmHg) 61 Favors First Listed Favors Second Listed 0.5 1.0 2.0 BP-Lowering Treatment Trialists Comparisons of different active treatments Lancet. In press. Relative Risk RR (95% CI) BP Difference (mm Hg) CA vs D/BB 1.33 (1.21, 1.47)1/0 0.93 (0.86, 1.01) CA vs D/BB 1/0 1.01 (0.94, 1.08) CA vs D/BB 1/0 ACE vs CA 0.82 (0.73, 0.92)1/1 1.12 (1.01, 1.25) ACE vs CA 1/1 0.96 (0.88, 1.05) ACE vs CA 1/1 Stroke Coronary Heart Disease Heart Failure 1.09 (1.00, 1.18) ACE vs D/BB 2/0 0.98 (0.91, 1.05) ACE vs D/BB 2/0 1.07 (0.96, 1.19) ACE vs D/BB 2/0 62 0.5 1.0 2.0 BP-Lowering Treatment Trialists Comparisons of different active treatments Lancet. In press. Relative Risk RR (95% CI) BP Difference (mm Hg) Favors First Listed Favors Second Listed Major CV Events CV Mortality Total Mortality 1.02 (0.98, 1.07)2/0 ACE vs D/BB 1.03 (0.95, 1.11)2/0 ACE vs D/BB 1.00 (0.95, 1.05)2/0 ACE vs D/BB 1.04 (0.99, 1.08)1/0 CA vs D/BB 1.05 (0.97, 1.13)1/0 CA vs D/BB 0.99 (0.95, 1.04)1/0 CA vs D/BB 0.97 (0.95, 1.03)1/1 ACE vs CA 1.03 (0.94, 1.13)1/1 ACE vs CA 1.04 (0.98, 1.10)1/1 ACE vs CA 63 BP-Lowering Treatment Trialists: Angiotensin Receptor Blocker vs Other RR (95% CI)Favors ARB Favors Other 0.5 1.0 2.0 Relative Risk 0.79 (0.69,0.90)Stroke 0.96 (0.85,1.09)CHD Heart Failure 0.84 (0.72,0.97) Major CV Events 0.90 (0.83,0.96) CV Death 0.96 (0.85,1.08) Total Mortality 0.94 (0.86,1.02) Outcome Lancet. In press. 64 BP-Lowering Treatment Trialists Stroke Systolic Blood Pressure Difference Between Randomised Groups (mm Hg) Relative Risk of Stroke0.25 0.50 0.75 1.00 1.25 1.50 -10 -8 -6 -4 -2 0 2 4 Systolic Blood Pressure Difference Between Randomised Groups (mm Hg) Relative Risk of CHD 0.25 0.50