recent advances targeting cardiovascular risk reduction...

Konstantinos P. Makaritsis Associate Professor of Medicine

University of Thessaly Medical School

Larissa, March 18, 2016

Recent advances targeting

cardiovascular risk reduction

Single-Pill Therapy with Amlodipine/ Atorvastatin

SATELLITE LECTURE Sponsored by WinMedica

Disclosures

Received scientific support and speaker honorarium from Sanofi, Bayer,

WinMedica & Amgen

Introduction

Hypertension is the most common of the chronic

diseases, affecting an estimated 1 billion adults

worldwide.

The prevalence of hypertension is rising, owing in

part to the increasing age of the population, the

increased rates of obesity and the increased

consumption of sodium in packaged and processed

foods.

Kearney PM et al. Lancet 365, 217–223 (2005).

Fields LE et al. Hypertension 44, 398–404 (2004).

National Health and Nutrition Examination Survey: 2007–2012.

Mozaffarian D et al. Circulation. 2015;131:e29-e322

Prevalence of hypertension is high

37,435,3

20,6

40,7

22 22,6

17

26,9

37,239,1

34,8

23,7

19,7

14,5

28,3

20,9

0

10

20

30

40

50

Men

Women

41,6

39,1

22,9

44,5

24

27,7

18,8

27

45,9

23,6

40,2

27 27

17,1

28,2

42,50

0

10

20

30

40

50

Established

market

countries

Former

socialist

economies

India Latin America

and the

Carribean

Middle

eastern

crescent

China Other Asia

and islands

Sub-Saharan

Africa

2000

2025

Pre

va

len

ce

of

hyp

ert

en

sio

n (

%)

Kearney PM et al.,Lancet. 2005;365:217-223.

Prevalence of hypertension in people aged 20 years and older

Hypertension is a leading cause

for cardiovascular morbidity

9.5

3.3 2.4 5.0

2.0 3.5 2.1

45.4

21.3

12.4

6.2

9.9 7.3

13.9

6.3

22.7

0

10

20

30

40

50

Men Women Men Women Men Women Men Women

Normotensive

Hypertensive

Coronary Disease Stroke Peripheral Arterial Disease

Heart Failure

Bie

nn

ial A

ge-A

dju

ste

d R

ate

p

er

1,0

00

36-Year Follow-up in Patients Aged 35-64 Years1,2

1. Kannel W.B. et al., JAMA 1996; 275: 1571-1576 2. Kannel W.B. et al., J Hum Hypertens 2000; 14: 83-90

Lewington et al. Lancet 2002;360:1903–13

Cardiovascular (CV) Mortality Risk Doubles with Each 20/10 mmHg

Increment in Systolic/Diastolic BP (SBP/DBP)*

*Individuals aged 40–69 years

CV mortality risk

0

2

4

8

115/75 135/85 155/95 175/105

6

SBP/DBP (mmHg)

2X

risk

4X

risk

8X

risk

1X risk

Antihypertensive drug therapy is effective

at reducing risk of CV events

-50

-40

-30

-20

-10

0

Heart failure1

Fatal/Nonfatal stroke1

Fatal/Nonfatal CHD1

Ris

k re

du

ctio

n (

%)

1. Moser and Herbert. J Am Coll Cardiol. 1996; 2. Collins R et al. Lancet 1990.

Vascular deaths

-52%

-38%

-16%

-21%

Average no. of antihypertensive medications

1 2 3 4

Multiple Antihypertensive Agents are

Needed to Reach BP Goal

Trial (SBP achieved)

1. Bakris et al. Am J Med 2004;116(5A):30S–8; 2. Dahlöf et al. Lancet 2005;366:895–906

3. Jamerson et al. Blood Press 2007;16:806; 4. Jamerson et al. N Engl J Med 2008;359:241728

ASCOT-BPLA (136.9 mmHg)

ALLHAT (138 mmHg)

IDNT (138 mmHg)

RENAAL (141 mmHg)

UKPDS (144 mmHg)

ABCD (132 mmHg)

MDRD (132 mmHg)

HOT (138 mmHg)

AASK (128 mmHg)

ACCOMPLISH (132 mmHg) Initial 2-drug combination therapy

USA

53.1

Canada

41.0

Mexico

21.8

Germany

33.6

Greece

49.5

England

29.2

Egypt

33.5

South Africa*

47.6

Japan*

55.7

Taiwan

18.0

China

28.8

Worldwide blood pressure control rates

in treated hypertensive patients are low

Kearney P.M. et al., J Hypertens 2004; 22: 11–19; * Data for men only

Turkey

19.8

Yusuf S et al. Lancet. 2004;364:937-952

36

12

7

10

20

33

0

20

40

60

80

100

Smoking Fruits/

Veg

Exercise Alcohol Psycho-

social

Lipids All 9 risk

factors

PA

R (

%)

14

18

90

Diabetes Abdominal

obesity

Hyper-

tension

Lifestyle factors

50

INTERHEART Study

n=15,152 patients and 14,820 controls in 52 countries

MI=Myocardial infarction, PAR=Population

attributable risk (adjusted for all risk factors)

Attributable Risk Factors for a First Myocardial Infarction

3.7

2.9

2.2

1.7

1.3

1.0

40 70 100 130 160 190

Re

lati

ve R

isk

fo

r C

oro

na

ry

He

art

Dis

ea

se

(L

og

Sc

ale

)

LDL-Cholesterol (mg/dL)

Grundy S et al. Circulation 2004;110:227-239

CHD=Coronary heart disease, LDL-C=Low-density lipoprotein cholesterol

Coronary Heart Disease Risk According to LDL-C Level

For advisory board purposes. Proprietary and confidential. Do not distribute.

Adapted from O’Keefe et al. J Am Coll Cardiol 2004;43:2142-6;

LaRosa JC et al. N Engl J Med 2005;352:1425-35.

25

20

15

10

5

0

CARE

TNT-80A TNT-10A

1.3 1.8 2.3 2.8 3.4 3.9 4.4 4.9 5.4 (mmol/L)

50 70 110 130 150 170 190 90 210 (mg/dL)

CH

D E

ve

nts

(%

)

LDL-C

Primary prevention trials

AFCAPS

WOSCOPS

ASCOT

AFCAPS

WOSCOPS

ASCOT

4S

CARE

LIPID

LIPID

Secondary prevention trials

Placebo

Placebo

4S

Active treatment

Active treatment

Lowering LDL-C With Statins Reduces CV Risk in Both Primary and Secondary Prevention

15

HMG-CoA Reductase Inhibitor Evidence: Effect of Intensive Therapy

Cholesterol Treatment Trialists’ (CTT) Collaboration Meta-analysis of 169,138 patients randomized to at least

2 years of statin therapy

0 1 2 3 4 5

0 10

15

20

LDL cholesterol level (mmol/L)

Five year risk of a major

vascular event, %

Control

21% relative risk reduction per mmol/L Statin

16% relative risk reduction per 0.5 mmol/L More statin

There is a proportionate reduction in CV events

with greater LDL-cholesterol reduction

Source: Cholesterol Treatment Trialists’ Collaboration. Lancet 2010;376:1670-1681

CV=Cardiovascular, LDL=Low density lipoprotein

18

Global mortality and burden of cardiovascular disease and major risk factors for people aged 30 years

Population All cardiovascular High blood pressure High cholesterol Overweight and obesity

Mortality Burden of disease

16 million

7.8 million

4.3 million

2.3 million

128 million

59 million

39 million

30 million

19

90.3% hypertensive patients have 3 risk factors

Most Hypertensive Patients Have Additional Risk Factors: REACH Registry

81.8% patients with

atherothrombosis have

HTN

Bhatt DL et al. JAMA. 2006;295:180-189.

HTN=hypertension; REACH=Reduction of Atherothrombosis for Continued Health.

Risk factors include: treated diabetes mellitus, diabetic nephropathy, asymptomatic carotid stenosis

≥70%, Systolic blood pressure [SBP], ≥150 mm Hg, treated hypercholesterolaemia, current smoking,

men ≥55 y, women ≥70 y.

N=67,888 patients aged 45 years or older from 44 countries

The overlap between hypertension, diabetes,

and dyslipidemia

Analysis of 137,745 insurance clients (Kaiser Permanente Medical Care Program, Northern California)

Selby JV et al. Am J Manag Care. 2004;10(part 2):163-70.

10%

56%

Diabetes +

Hypertension +

Dyslipidemia

18% Diabetes +

Hypertension

16% Diabetes +

Dyslipidemia

Diabetes

21

Majority of Hypertensive Patients Have LDL-C ≥100 mg/dL

Source: NHANES III Phase 2 Morning Fasting Subset. 2000 Census Data.

(Unweighted N = 7697; Weighted Sample = 200,948,641)

Only 14.3% of hypertensive have LDL-C <100 mg/dL

<100 mg/dL

100 - <130 mg/dL

130 - <160 mg/dL

160 - <190 mg/dL

190 mg/dL

Frequency of Hypertensive Patients by LDL-C Levels

14.3%

26.8%

33.7%

17.4%

7.7%

0

Pa

tie

nts

(%

)

10

20

30

40

50

22

Most Patients Diagnosed With Hypertension and Dyslipidemia Were Not at Both Goals

In a managed care population, the vast majority of patients diagnosed with hypertension and dyslipidemia (n = 154,235)

were not at both goals

As the number of CV risk factors increased,

the rate of goal attainment decreased

CV = cardiovascular.

Pettitt D et al. Poster presented at: 26th Annual Meeting of the Society of General

Internal Medicine 2003; Vancouver, Canada.

More than

90% were

not at both

goals

Less than

10% were

at both

goals

23

Multiple CV Risk Management Results in Dramatic Reductions in CVD

10%

Reduction

in BP

10%

Reduction

in TC + 45%

Reduction

in CVD =

Emberson J et al. Eur Heart J. 2004;25:484-491.

Jackson R et al. Lancet. 2005;365:434-441.

“Attention should be moved from knowing one’s BP and cholesterol

concentrations to knowing one’s absolute CV risk and its

determinants.”

– J. Emberson et al

- Jackson et al

Journal of Hypertension. 2013;31:1281–1357.

Stratification of total CV risk in categories

Journal of Hypertension. 2013;31:1281–1357.

Journal of Hypertension. 2013;31:1281–1357.

Treatment of risk factors associated with hypertension

Adherence

Arch Intern Med. 2005;165:1147-1152

Patient adherence and medication number

Chapman et al. Arch Intern Med 2005;165:1147–52

Nu

mb

er

of m

ed

ica

tio

ns

1,73 (1,56–1,90, p<0,001)

1,25 (1,13-1,39, p<0,001)

0,96 (0,86–1,06, p=0,41)

0,87 (0,79-0,94, p<0,001)

0,65 (0,59-0,71, p<0,001)

0.5 1 1.5 2 2.5

↓Adherence

0

1

2

3–5

≥ 6

Adherence Decline

↑Adherence

Vasc Health Risk Manag. 2008; 4(3): 673–681.

SPAA patients (1-pill) were more likely to be adherent (OR = 4.7, p < 0.001) than CCB/statin patients.

Being adherent to either regimen was associated with significantly lower risk of CV event (HR = 0.77, p = 0.003).

Being adherent to SPAA was associated with significantly lower risk of CV event vs. CCB/statin patients (HR = 0.68, p = 0.02).

Conclusions: Patients receiving SPAA rather than a 2-pill CCB/statin regimen are more likely to be adherent. Adherence to CCB and statin medications is associated with lower risk of CV events in primary prevention patients.

17,910 CCB/statin patients Retrospective study

Clinical Studies

Zarvalor

Zarvalor Zarvalor

Zarvalor

Zarvalor Zarator Norvasc

J Clin Hypertens. 2005;7:264–273

Zarvalor

Zarvalor

Criteria for Assignment to CV Risk Categories & Recommended BP & LDL-C Target Levels for Each Risk Group

J Clin Hypertens. 2005;7:264–273

Goal attainment at end point overall and within each of the three cardiovascular risk groups

J Clin Hypertens. 2005;7:264–273

Zarvalor

J Clin Hypertens. 2006;8:571–581.

The AVALON study was a randomized, multicenter trial to assess the efficacy and safety of co-administered amlodipine and atorvastatin in patients with hypertension and dyslipidemia. Phase 1 was an 8-week, double-blind, placebo-controlled period whereby patients received amlodipine 5 mg, atorvastatin 10 mg, amlodipine 5 mg and atorvastatin 10 mg, or placebo.

J Clin Hypertens. 2006;8:571–581.

Week 28 (all pts were receiving coadministered AML and ATV).

Percentage of patients that reached target levels for both blood pressure and low-density lipoprotein cholesterol

Week 8 (Weeks 0-8 : Double-blind period).

European Journal of Cardiovascular Prevention and Rehabilitation 2009, 16:472–480

58

JEWEL: Objectives

Evaluate the utility of single-pill

amlodipine/atorvastatin in European and Canadian

real-world primary care settings

Assess the efficacy of amlodipine/atorvastatin to

achieve national lipid and hypertension goals as set

out in clinical guidelines

European Journal of Cardiovascular Prevention and Rehabilitation 2009, 16:472–480

59

JEWEL Design

16-week multicentre, open-label, titration-to-goal study in

patients with hypertension and dyslipideamia

– JEWEL I: UK and Canada

– JEWEL II: 11 EU countries (Italy, Ireland, Belgium, Spain,

Greece, Switzerland, Austria, Portugal, Finland, Hungary,

Slovenia)

Eight dosage strengths of single-pill amlodipine/atorvastatin

therapy (5/10, 10/10, 5/20, 10/20, 5/40, 10/40, 5/80, 10/80

mg/mg) were titrated to reduce BP and LDL-C to country-

specific target levels

1 Hobbs FD et al. Int J Cardiol 2006;110:242-50. European Journal of Cardiovascular Prevention and Rehabilitation 2009, 16:472–480

60

Study Population

Inclusion criteria:

– Male or female aged 18–80 years

– Diagnosis of concurrent hypertension (uncontrolled) and dyslipideamia (controlled or uncontrolled)

– Untreated, or if treated on stable medication

– BP above target, LDL-C must be above target or (if on treatment), at or above target

Exclusion criteria:

– Adequately controlled BP at baseline

– Currently receiving treatment with:

• Amlodipine and atorvastatin

• Atorvastatin 80 mg but with a LDL-C ≥2.6 mmol/L (100 mg/dL)

– Treated with amlodipine 10 mg or another CCB at maximum dose

61

Patients Achieving Common BP and LDL-C Goals

Amlodipine/atorvastatin

All doses

Amlodipine/atorvastatin

5/10 mg or 10/10 mg

JEWEL I JEWEL II0

20

40

60

80

100

(n=1135) (n=1084)

55.0% 56.0%

Pa

tie

nts

(%

) re

ach

ing

bo

th

BP

an

d L

DL

-C

co

mm

on

go

als

(

CI)

JEWEL I JEWEL II0

20

40

60

80

100

(n=476) (n=478)

52.5% 56.3%

JEWEL I JEWEL II0

20

40

60

80

100

(n=1135) (n=1084)

55.0% 56.0%

Pa

tie

nts

(%

) re

ach

ing

bo

th

BP

an

d L

DL

-C

co

mm

on

go

als

(

CI)

JEWEL I JEWEL II0

20

40

60

80

100

(n=476) (n=478)

52.5% 56.3%

Common goals defined as: LDL-C <3.0 mmol/L (116.0 mg/mL)

SBP <140 and DBP <90 mm Hg; Patients with diabetes: SBP <130 and DBP <80 mm Hg

62

Patients Achieving Common BP Goal only

Amlodipine/atorvastatin

All doses

Common BP goal defined as: SBP <140 and DBP <90 mm Hg;

Patients with diabetes: SBP <130 and DBP <80 mm Hg

JEWEL I JEWEL II0

20

40

60

80

100

(n=1135) (n=1084)

65.7%58.1%

Pa

tie

nts

(%

) re

ach

ing

BP

co

mm

on

go

al (

CI)

JEWEL I JEWEL II0

20

40

60

80

100

(n=1135) (n=1084)

61.3%54.0%

Amlodipine/atorvastatin

5/10 mg or 10/10 mg

JEWEL I JEWEL II0

20

40

60

80

100

(n=1135) (n=1084)

65.7%58.1%

Pa

tie

nts

(%

) re

ach

ing

BP

co

mm

on

go

al (

CI)

JEWEL I JEWEL II0

20

40

60

80

100

(n=1135) (n=1084)

61.3%54.0%

63

Mean Change in Blood Pressure and LDL-C

Amlodipine/atorvastatin

5/10 mg or 10/10 mg

SBP DBP SBP DBP

-30

-20

-10

0

JEWEL I JEWEL II

-19.3

-10.2

-20.4

-12.2

Mean c

hange (C

I)

in B

P (

mm

Hg)

-1.5

-1.0

-0.5

0.0

JEWEL I JEWEL II

-0.85 mmol/L(-32.9 mg/dL)

-0.95 mmol/L(36.7 mg/dL)

-0

-10

-20

-30

-40

-50Mean c

hange (C

I)

in L

DL-C

(m

mol/L)

mg/d

L

Blood Pressure LDL-C

73

Single-Pill Amlodipine/Atorvastatin (Zarvalor)

A single-pill combination therapy targeting hypertension and

dyslipidemia is useful in:

– Co-treatment of these 2 CV risk factors by treating a

patient’s overall risk of cardiovascular disease

– Lower prescription costs

– Reduce a patient’s pill burden and improve patient

adherence

The efficacy and safety of this combination has been

demonstrated in a clinical practice setting, in several studies.

– Furthermore, patients taking the single pill

amlodpine/atorvastatin are more likely to be adherent with

both therapies.

Journal of Hypertension. 2013;31:1281–1357.

Treatment of risk factors associated with hypertension

Thank You

The Ancient Theatre of Larissa, Greece

3rd Century B.C.