IPERTENSIONE ARTERIOSA

Transcript

1 IPERTENSIONE ARTERIOSA

2 Rischi assoluti di mortalità per coronaropatia ed ictus per decade di età (scala logaritmica) per livello di PA abituale (scala lineare) Meta-analysis of 61 prospective studies Prospective Studies Collaboration, Lancet, 2002

3 Un difficile equilibrio tra età, comorbidità e fragilità. Valutazione funzionale necessaria Comorbidità 65 aa anziani Aspettativa di vita 80 aa vecchi Fragilità

4 L anziano ha : Più frequentemente ipertensione sistolica isolata Più frequentemente ipotensione ortostatica Più frequentemente effetto camice bianco Più frequentemente ipertensione notturna Più ampia variabilità pressoria Più facilmente effetti collaterali da farmaci

5 E piuttosto facile misurare male la pressione arteriosa

6 METODO DI MISURAZIONE P.A. braccio denudato schiena sostenuta avambraccio sostenuto gambe non accavallate e piedi piantati sul pavimento

7 Automated Office BP measurement (AOBP) unattended/unobserved Studies comparing automated office BP with awake ambulatory BP e-journal of the ESC Council for Cardiology Practice.VOL.13,N MAR 2015 Study Subjects Settings AOBP Awake ABP Beckett and Godwin 481 Family practice 140/80 142/80 Myers et al 309 ABPM 132/75 134/77 Myers et al 62 Hypertension Clinic 140/77 141/77 Myers et al 254 ABPM 133/80 135/81 Godwin et al 654 Family Practice 139/80 141/80 Myers et al 139 ABPM 141/82 142/81 Myers et al 303 Family Practice 136/78 133/74 Mean 138/79 139/79

8 Esistono sottogruppi in cui il trattamento può essere inutile o perfino dannoso? Rischio aggiuntivo con target più bassi? Nessun beneficio?

9 patients Published online August 30, 2016

10 Effects of Low Blood Pressure in Cognitively Impaired Elderly Patients Treated With Antihypertensive Drugs Multivariable Analysis of MMSE Score Change by AHD Treatment and Daytime and Office SBPs.predict the progression of cognitive decline in patients with overt dementia and mild cognitive impairment (MCI) Mossello E. JAMA Intern Med (4):578

11 Bavishi C : JACC 2017; 69: 486

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13 SPRINT Study: outcome Adults aged 75 yrs 7 Grandangolo in Medicina Interna Genova, 25 Marzo 2017

14 Characterizing frailty status in the systolic blood pressure intervention trial item frailty index (FI) 2. Scores range from 0 to 1 higher values denote more deficits 55.2% less fit (>0,10-0,21) 30.9% frail (>0,21) > 0.7 not observed Pajewski NM et al; SPRINT Study Research Group. J Gerontol A Biol Sci Med Sci.2016;71(5):

15 Relationship of FI with Age 1. Single dash lines: Estimates from National Long Term Care Survey Kulminski et al. Mech Ageing Dev 2006;127: Double dash lines: 10-year mean FI values from Survey of Health, Ageing and Retirement in Europe (SHARE) Romero-Ortuno and Kenny. Age Ageing 2012;41(5): Solid lines: Fit based on local polynomial regression in SPRINT with 95% CIs (shaded areas) Pajewski NM et al; SPRINT Study Research Group. J Gerontol A Biol Sci Med Sci.2016;71(5):

16 Lessons in Uncertainty and Humility Clinical Trials Involving Hypertension Trials Influencing Blood-Pressure Thresholds at Which Antihypertensive Medications Should Be Used. MA Pfeffer and JJV McMurray.N Engl J Med 2016;375:1756

17 Linee guida 2013 ESH/ESC Quando iniziare la terapia antipertensiva e quali target nell anziano <80 >80

18 Intensive Versus Standard BP Lowering in Older Hypertensive Patients 4 high-quality trials involving 10,857 older hypertensive patients mean follow-up of 3.1 years.

19 Falls, Fractures, and Syncope We found moderate-strength evidence from 3 large trials with low risk of bias that more intensive BPtreatment (SBP targets <120 and <150 mm Hg and achieved SBP <150 mm Hg) did not increase risk for fracture (43, 44). We found low-strength evidence that more aggressive BP control did not consistently increase risk for falls. Two of the trials found that very aggressive BP lowering (SBP <120 mm Hg) did not increase risk for falls (3, 43), whereas a third trial found that moderate BP control (SBP <150 mm Hg) was associated with a small increase in risk for falls (26). We found low-strength evidence of increased risk for syncope from more aggressive BP control across 3 trials with achieved SBP ranging from to 143 mm Hg (RR, 1.52 [CI, 1.22 to 2.07]) Weiss J : Ann Intern Med. doi: /m published at on 17 January 2017.

20 Data relevant to frail elderly adults and the effect of multimorbidity are limited Weiss J : Ann Intern Med. doi: /m published at on 17 January 2017.

21 Tutte queste medicine mi intossicano Inerzia terapeutica Farmaci, istruzioni per l uso

22 NICE Hypertension guidelines Drug treatment

23 Quarter-dose quadruple combination therapy for initial treatment of hypertension: placebo-controlled, crossover, randomised trial and systematic review. the quadpill concept irbesartan 37 5 mg, amlodipine 1 25 mg, hydrochlorothiazide 6 25 mg, and atenolol 12 5 mg Chow CK et al. Lancet Feb 9. pii: S (17)30260-X.

24 Treating hypertension in the frail elderly Stop or decrease treatment Taper and discontinue antihypertensive drugs if seated systolic blood pressure is less than 140 mm Hg, but: It is not certain whether to discontinue treatment if the patient has a history of stroke The target seated systolic blood pressure can be adjusted upward if there is symptomatic orthostasis or if standing systolic blood pressure is less than 140 mm Hg, Before stopping, consider whether the medication is treating additional conditions such as atrial fibrillation or symptomatic heart failure Start or increase treatment Consider treatment if systolic blood pressure is 160 mm Hg or higher Aim for a seated systolic blood pressure of 140 to 160 mm Hg Use seated (not supine) blood pressure to make treatment decisions In the very frail with short life expectancy, a target systolic blood pressure of 160 to 190 mm Hg is reasonable In general, use no more than two medications Mallery LH : CCJM 2014; 2:427

25 Conclusioni Potrebbe essere ragionevole abbassare la pressione arteriosa sistolica tra 140 e 130 mmhg in soggetti anziani non molto fragili e ad alto rishio CV ma senza causare sintomi, disfunzione renale, disionie, ischemia COME? 1. Una buona misurazione pressoria 2. Valutazione iniziale delle comorbilità e della fragilità 3. Un approccio a gradini basato sulla PAS: ??? 4. Un occhiata alla PAD 5. Una buona alleanza terapeutica con il paziente

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