case hypertension and chest pain
TRANSCRIPT
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CASE STUDY
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A 55 y.o man complained of chest discomfort when exercising sincethe last 2 months.. He admitted suffering from both hypertensionand DM2 . No history of MI, CHD or stroke. He is a heavy smoker.Currently he is on Glibenclamide 5 mg (1-0-) and Rampiril 1 x 10mg.
BP 150/90 mmHg HR 78/m
ECG : SR, LVH
LDL 126 mg/dL, TG 144 mg/dL. The kidney function and liver
function are normal
01 Case Study
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02 What are the Patients Problem?
1. Cigarette smoker
2. Hypertension
3. Diabetes Mellitus
4. Dyslipidemia
5. Chest discomfort
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03 What are the Patients Problem?
Cigarette smoker
Hypertension
Diabetes Mellitus
Dyslipidemia
Chest discomfort
YesYes
Yes
Yes
Yes !
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Is there any way to preventcardiovascular event,considering CVD is the leadingcauses (67%)1 of morbidity and
mortality among Hypertensionand DM patients?
04
1. Alexander CM, Antonello S. Pract Diabet. 2002;21:21-8 2. Colhoun HM et al. Lancet. 2004;364:685-696
A. Yes
B. No
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Is there any way to preventcardiovascular event,considering CVD is the leadingcauses (67%)1 of morbidity and
mortality among Hypertensionand DM patients?
05
Yes
1. Alexander CM, Antonello S. Pract Diabet. 2002;21:21-8 2. Colhoun HM et al. Lancet. 2004;364:685-696
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ACS
Coronary
Thrombosis
Myocardial
Ischemia
CAD
Atherosclerosis
Risk Factors
( Dyslipidemia, BP, DM,Insulin Resistance, Platelets,
Fibrinogen, etc) Adapted fromDzau et al. Am Heart J. 1991;121:1244-1263
The cardiovascular continuum of events
Arrhythmia andLoss of Muscle
Remodeling
Ventricular
Dilatation
Congestive
Heart Failure
End-stage
Heart Disease
Primaryprevention
Secondaryprevention Stroke
Important
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8
Progression of HT to LVH to HF
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BAGAIMANA PASIEN HARUS DIKELOLA?
06
Tentukan risiko pasien ini. Bagaimana caranya?Apakah perlu diperiksa marker untuk sindrom
koroner akut?
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Category Systolic Diastolic
Optimal
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Assessment of the overall cardiovascular risk
Cardiovascular Risk Factors
Presence of Risk Factors
- Increasing age- Male gender- Smoking- Family history of premature cardiovascular disease (age< 55 in men and
< 65 in women)
- Dyslipidemia- Sedentary lifestyle
- Unhealthy eating- Abdominal obesity- Dysglycemia (diabetes, impaired glucose tolerance, impaired fasting
glucose)
Presence of Target Organ Damage- Microalbuminuria or proteinuria
- Left ventricular hypertrophy- Chronic kidney disease (glomerular filtration rate < 60 ml/min/1.73 m2)
Presence of atherosclerotic vascular disease- Previous stroke or TIA- Coronary Heart Disease- Peripheral arterial disease
CV Risk Factors that may alter thresholds and targets in the treatment of HTN2009 CHEP Recommendations
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CKMB dan Troponin dalam batasnormal
Adakah pemeriksaan lain diperlukan?
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13
Chest PA view of Heart - LVH
C/T ratio > 50%
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Click to edit Master title styleClick to edit Master title styleBAGAIMANA RISIKO PASIEN INI?
RENDAH ?
SEDANG ?
TINGGI?
SANGAT TINGGI ?
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Very high
added risk
High
added risk
High
added risk
High
added risk
Moderate
added risk
3 risk factors,
mets, organdamage, or diabetes
Very high
added risk
Very high
added risk
Very high
added risk
Very high
added risk
Very high
added risk
Established CV or
renal disease
Very highadded riskModerateadded riskModerateadded riskLow addedriskLow addedrisk1-2 risk factors
High added
risk
Moderate
added risk
Low added
risk
Average
risk
Average
riskNo other risk factors
Grade 3 HTGrade 2HT
Grade 1HT
Highnormal
NormalOther risk factor,
organ damage, ordisease
Blood pressure (mm Hg)
HT: hypertension; mets: metabolic syndrome; CV: cardiovascular
Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187
Cardiovascular Risk Stratification
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Click to edit Master title styleClick to edit Master title styleBAGAIMANA SEHARUSNYA PASIEN INI DIKELOLA?
Merokok
Hypertensi Diabetes Mellitus
Dyslipidemia
Chest discomfort
Obat Anti-hypertensive
Stop Merokok Merubah
gaya hidup
Obat Hypoglicaemic
Obat Hypolipidemic
Obat anti-hipertensi
Obat anti iskemia
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Hypertension and subcinical organ damage
data obtained in the LIFE study, in which hypertensivepatients in whom treatment was accompanied byregression of echocardiographic
LVH or a delayed increase in LVM had less
incident cardiovascular events, including sudden death,than those in whom no regression from or earlierprogression to LVH occurred.
Mancia et al Reappraisal of ESC/ESH 2007 Guidelines on Hypertension
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Cardiac Hypertrophy in Hypertension
Cardiac hypertrophy (LVH)
1. Regression of cardiac hypertrophy leads to animprovement in prognosis.
2. Any antihypertensive drug can induce the regression ofcardiac hypertrophy by maintaining a sufficient decrease inblood pressure. The target of blood pressure controlshould be
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Hypertension and coronary heart disease
1. Careful and sufficient reduction of blood pressure is important
in coronary artery disease. The target of blood pressure control shouldbe
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Whats New for 2009The Hypertensive Diabetic
Patients with diabetes are at high cardiovascularrisk
Up to 80% of diabetic patients die of cardiovascular
disease Most patients with diabetes have hypertension
Between 35 and 75% of diabetic complicationshave been attributed to hypertension.
Treatment of hypertension in patients with
diabetes reduces total mortality, myocardialinfarction, stroke, retinopathy and progressiverenal failure rates.
More intensive reduction in blood pressurereduces major cardiovascular events and totalmortality by 25%
Treating hypertension in the diabetic patient reduces death and disability and reduces
health care system costsTARGET
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Blood Pressure Evidence: Primary Prevention
0 1 2 3 4 5 6 70
.04
.08
.12
.16
.20
RR (95% CI) P-value
A/C 0.98 (0.90-1.07) 0.65
L/C 0.99 (0.91-1.08) 0.81RateofM
Ior
fatalCH
D
Antihypertensive and Lipid-Lowering Treatment to Prevent
Heart Attack Trial (ALLHAT)
ALLHAT Investigators. JAMA 2002;288:2981-97
Years to CHD Event
BP=Blood pressure, CHD=Coronary heart disease,HTN=Hypertension, MI=Myocardial infarction
Chlorthalidone
Amlodipine
Lisinopril
33,357 patients with HTN and >1 CHD risk factor randomized to chlorthalidone, amlodipine, orlisinopril for 5 years
There is similar efficacy among BP lowering agents
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0 6 12 18 24 30 36 42 48 54 60 66
Study Month
4
8
12
16
0ProportionwithCV
death,
MI,orstroke(%)
Blood Pressure Evidence: Primary Prevention
Losartan Intervention for Endpoint (LIFE) Reduction in
Hypertension Study
Dahlf B et al. Lancet2002;359:995-1003
AtenololLosartan
13% RRR, P=0.021
ARB=Angiotensin receptor blocker, CV=Cardiovascular,
DBP=Diastolic blood pressure, LVH=Left ventricular hypertrophy,
MI=Myocardial infarction, SBP=Systolic blood pressure
*Defined by SBP=160-200 mmHg or DBP=95-115 mmHg
9,193 high-risk hypertensive* patients with LVH randomized to losartan (100 mg) or atenolol(100 mg) for 5 years
An ARB provides greater efficacy in patients with LVH
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Anglo-Scandinavian Cardiac Outcomes TrialBlood Pressure
Lowering Arm (ASCOT-BPLA)
Blood Pressure Evidence: Primary Prevention
NonfatalMI
and
fatalCHD(
%)
6
2
4
0
1 2 3 4 5 60
Time since randomization (years)
RRR = 10%, P = 0.1052
Atenolol-based regimen
Amlodipine-based regimen
Dahlf B et al. Lancet2005;366:895-906
BP=Blood pressure, CV=Cardiovascular, CHD=Coronaryheart disease, MI=Myocardial infarction
19,342 high-risk hypertensive patients with 3 additional CV risk factors randomized toamlodipine (10 mg) & perindopril (8 mg) or atenolol (100 mg) & bendroflumethiazide (2.5
mg) for 5.5 years
There is similar efficacy with both BP lowering regimens
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HOPE Study (Usefulness of ACEi)Relative Risk Reduction of Cardiovascular Endpoints in high riskpatients (angina, DM, HTN, PAOD) with normal LV Fx.
CombinedCardiovascular
endpointsCardiovascular
mortalityMyocardialinfarction
Stroke
-22% p
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Favors valsartan Favors amlodipine
Primary cardiac composite endpoint
Cardiac mortality
Cardiac morbidity
All myocardial infarction
All congestive heart failure
All stroke
All-cause death
New-onset diabetes
0.5 1 2
Blood Pressure Evidence: Secondary Prevention
Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) Trial
Julius S et al. Lancet2004;363:2022-2031
ARBS=Angiotensin receptor blocker, CCB=Calciumchannel blocker, CV=Cardiovascular
15,245 patients with untreated HTN and high CV risk randomized to a BP
lowering strategy with valsartan (160 mg) or amlodipine (10 mg) for 4.2 years
There is similar efficacy with an ARB and CCB
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Nissen S et al. JAMA 2004;292:2217-26
Blood Pressure Evidence: Secondary Prevention
Comparison of Amlodipine vs Enalapril to Limit Occurrences of
Thrombosis (CAMELOT) Trial
*Includes CV death, myocardial infarction, cardiac arrest, coronary revascularization, hospitalization for heart
failure or angina pectoris, stroke, transient ischemic attack, development of peripheral arterial disease
CVevent
rate*
0
0.25
0.20
0.10
0.05
6 12 18 24
0.15
0
Placebo
Amlodipine
Enalapril
Months
Follow-up BP
(mmHg)
125/77
124/77
130/78
BP=Blood pressure, CAD=Coronary artery disease,CV=Cardiovascular, DBP=Diastolic BP
1,991 patients with CAD and a DBP
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2,028 patients with symptomatic HF, LVSD (EF
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ARB Evidence: Secondary Prevention
Pfeffer M et al. NEJM2003;349:1893-1906
Valsartan in Acute Myocardial Infarction Trial (VALIANT)
0.0
0.1
0.2
0.3
0.4
0 6 12 18 24 30 36
Valsartan
Valsartan and Captopril
Captopril
AllC
auseMo
rtality
Months
Valsartan vs. Captopril: HR = 1.00; P = 0.982
Valsartan + Captopril vs. Captopril: HR = 0.98; P = 0.726
ACE-I=Angiotensin converting enzyme inhibitors,
ARB=Angiotensin receptor blockers, EF=Ejection
fraction, LVSD=Left ventricular systolic dysfunction
14,703 patients with post-MI HF or LVSD (EF
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Anglo-Scandinavian Cardiac Outcomes TrialLipid Lowering Arm (ASCOT-LLA): StudyDesign
Nonfatal MI, including silent MI, and fatal CHD
Primary efficacy end point
HTN=hypertension; SBP=systolic blood pressure; DBP=diastolic blood pressure; TC=total cholesterol;
CVD=cardiovascular disease.
Sever PS et al. Lancet. 2003;361:1149-1158.
Men and women aged40-79 years
Untreated HTN(SBP 160 mm Hg,DBP 100 mm Hg, or both)
Treated HTN(SBP 140 mm Hg,DBP 90 mm Hg, or both)
TC 251.4 mg/dL
At least 3 additional
CVD risk factors
Atorvastatin 10 mg(n=5168)
Placebo
(n=5137)
Patient population
5 years
19,342
patients
with HTN
10,305
patients with
TC 251.4 mg/dL
Trial stopped at 3.3 years,
2 years earlier than expected
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RRR=relative risk reduction.
Adapted from Sever PS et al. Lancet. 2003;361:1149-1158.
ASCOT-LLA: Atorvastatin Reduced theOccurrence of First Major CV Events
4
0
1
2
3
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
Years
36% RRR in
nonfatal MI and
fatal CHD
P=.0005
Atorvastatin(10 mg)
Placebo
PatientswithnonfatalMIand
fatalCHD
(%)
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Click to edit Master title styleClick to edit Master title styleBaseline Characteristics JIKEI
Clinicalcharacteristics
Valsartan arm(n=1,541)
Non-ARB arm(n=1,540)
Male 1,020 (66%) 1,023 (66%)
Female 521 (34%) 517 (34%)
Age (years) 65 (10) 65 (10)
Current smoker 259 (17%) 262 (17%)
Systolic BP [SBP]
(mmHg) 139.2 (11.4) 138.8 (10.6)
Diastolic BP [DBP](mmHg) 81.4 (10.5) 81.4 (10.8)
Heart rate (beats/min)
BMI (kg/cm2)
71 (11)
24(3)
72 (11)
24(3)
Note: Data are mean (Standard Deviation) or Number (%)
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Click to edit Master title styleClick to edit Master title styleMedical History at Baseline
Concomitant Diseases
Valsartan arm
(n=1,541)
Non-ARB arm
(n=1,540)
Hypertension 1,358 (88%) 1,341 (87%)
Coronary heart disease 514 (33%) 522 (34%)
Heart failure 176 (11%) 174 (11%)
Hyperlipidaemia 812 (53%) 813 (53%)
Diabetes mellitus 315 (20%) 314 (20%)
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Click to edit Master title styleClick to edit Master title styleEffect of Treatment on Endpoints JIKEI STUDY
Primary endpo intComposite endpoint
Secondary endpoints
Stroke/TIA
Myocardial infarction
Hospitalisation for angina pectoris
Hospitalisation for Heart Failure
Dissecting aortic aneurysm
Transition to dialysis, doubling
of serum creatinine levels
All cause mortality
Cardiovascular mortality
0.0002
0.0280
0.7545
0.0001
0.0293
0.0340
0.8966
0.7537
0.9545
P-value
TIA = transient ischaemic attack
Incidence increasedIncidence of endpoint reduced
0.125 0.25 0.5 1 2 4
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Click to edit Master title styleClick to edit Master title stylePrimary Endpoint
0 6 12 18 24 30 36 42 48
Number at risk
Valsartan 1,541 1,504 1,441 1,257 1,092 855 689 368 368
Non-ARB 1,540 1,502 1,447 1,262 1,075 835 657 344 343
15
10
5
0
Eventrate
(%)
Valsartan arm (92 events)
Non-ARB arm (149 events)
HR=0.61, p=0.0002
95% CI 0.470.79
39%
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Click to edit Master title styleClick to edit Master title styleHospitalisation for Angina Pectoris
0 6 12 18 24 30 36 42 48
Number at risk
Valsartan 1,541 1,504 1,441 1,257 1,092 855 689 368 368
Non-ARB 1,540 1,504 1,450 1,265 1,078 837 658 343 343
4
3
2
1
0
Eventrate
(%)
Valsartan arm 19 events
Non-ARB arm 53 events
HR=0.35, p=0.000195% CI 0.200.58
65%
Source: Kaplan Meier Curve adopted from Dr Dahlof ESC 2006 Hotline presentation
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Click to edit Master title styleClick to edit Master title styleHospitalisation for Heart Failure
0 6 12 18 24 30 36 42 48
Number at risk
Valsartan 1,541 1,504 1,441 1,257 1,093 856 690 369 368
Non-ARB 1,540 1,502 1,448 1,264 1,077 837 657 343 343
2.5
2.0
1.5
1.0
0.5
0.0
Eventrate
(%)
Valsartan arm 19 events
Non-ARB arm 36 events
HR=0.53, p=0.029
95% CI 0.310.94
47%
Source: Kaplan Meier Curve adopted from Dr Dahlof ESC 2006 Hotline presentation
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Phase ofTreatment
Acute
treatment
Secondaryprevention
Overall
Total #Patients
28,970
24,298
53,268
0.5 1.0 2.0
RR of deathb-blocker
better
RR (95% CI)
Placebo
better
0.87 (0.77-0.98)
0.77 (0.70-0.84)
0.81 (0.75-0.87)
b-blocker Evidence: Secondary Prevention
Antman E, Braunwald E. Acute Myocardial Infarction.
In: Braunwald E, Zipes DP, Libby P, eds. Heart Disease:
A textbook of Cardiovascular Medicine, 6th ed.,
Philadelphia, PA: W.B. Sanders, 2001, 1168.
Summary of Secondary Prevention Trials ofb-blocker Therapy
CI=Confidence interval, RR=Relative risk
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ASPIRIN IN HYPERTENSION
the prudent recommendations of the 2007 ESH/ESC guidelines can bereconfirmed: antiplatelet therapy, in particular low-dose aspirin, shouldbe prescribed to hypertensive patients with previous cardiovascularevents;
it can also be considered in hypertensive patients without a history ofcardiovascular disease with reduced renal function or with a highcardiovascular risk.
In patients receiving aspirin, careful attention should always be given to theincreased possibility of bleeding,particularly gastrointestinal.
Mancia et al. Reappraisal of 2007 ESC/ESH Guidelines on Hypertension
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2nd Prevention of aspirin
- CV death 17% - AMI 34%
- CVA 35%
- All CV disease 35%
AHA ecommendation :Anyone with atherosclerosis
Initial Tx: 160-325mg at 1st day
Subsequent Tx: 75-160 mg/day
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Anti-anginal Drug
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Click to edit Master title styleClick to edit Master title styleJADI, BAGAIMANA GARIS BESAR PENGOBATAN?
ASPIRIN / ANTIPLATELET ?
THIAZIDE
BETA BLOCKER
CALCIUM CHANNEL BLOCKER
NITRAT
ACE-INHIBITOR
ARB
VASODILATOR LAIN
ANTI DIABETIK
HIPOLIPIDEMIK
LAIN-LAIN ?
Terapi Kombinasi
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Click to edit Master title styleClick to edit Master title styleADAKAH PEMERIKSAAN LAIN YANG DIPERLUKAN?
Laboratorium : ??
Treadmill Test ?
Ekhokardiogram
MSCT ?
Angiografi koroner/kateterisasi jantung ?