Upload
vocong
View
215
Download
0
Embed Size (px)
Citation preview
Ipertensione e Rischio Cardiovascolare
Alberto Morganti
U.O. Medicina Generale, Centro Ipertensione ArteriosaOspedale San Giuseppe, Università di Milano
Abuso di sale, Obesità e IpertensioneMinistero della salute
Roma, 14 giugno 2010
Mortalità dovuta ai principali fattori di rischio globale (WHO World Health Report 2002)
Ezzati et al., Lancet 2002
8000
7000
6000
5000
4000
3000
2000
1000
0
Mor
talit
àat
trib
uib
ile (
x 1
00
0) Alta mortalità, Paese in via di sviluppo
Più bassa mortalità, Paese in via di sviluppoPaese industrializzato
Iper
tens
ione
iper
cole
ster
olem
ia
Sess
o no
n pr
otet
to
Elev
ato
BMI
Pollu
zion
e at
mos
feric
a ur
bana
Def
icit
Vit.
A
Inqu
inam
ento
da
part
icol
ari
ambi
enti
di la
voro
Espo
sizi
one
al p
iom
bo
Taba
cco
Peso
infe
riore
alla
nor
ma
Bass
o c
onsu
mo
di f
rutt
a e
verd
ura
Inat
tività
fisic
a
Acqu
a in
quin
ata
e ca
renz
e ig
ieni
che
Def
icit
di f
erro
Def
icit
di z
inco
Uns
afe
heal
th-c
are
inje
ctio
ns
Fatt
ori d
i ris
chio
oc
cupa
zion
ali
Sost
anze
ill
ecite
Alco
ol
0877 Z
Fum
o in
door
0 5 10 15 20 25
Other CV disease Hypertensive disease Ischaemic heart disease Stroke
2259 Mo2259 Mo
DisabilityDisability--adjusted Life Years (DALYs) Attributable to adjusted Life Years (DALYs) Attributable to High Blood Pressure by Region and Endpoint in 2001High Blood Pressure by Region and Endpoint in 2001
Lawes CMM et al., Lancet 2008; 371: 1513Lawes CMM et al., Lancet 2008; 371: 1513--15181518
Wor
ld B
ank
regi
ons
Wor
ld B
ank
regi
ons
Attributable DALYs (1000000s)Attributable DALYs (1000000s)
East Asia and PacificEast Asia and Pacific
Europe and central AsiaEurope and central Asia
Latin America andLatin America andthe Caribbeanthe Caribbean
Middle East and north AfricaMiddle East and north Africa
South AsiaSouth Asia
SubSub--Saharan AfricaSaharan Africa
HighHigh--income economiesincome economies
Numero di Soggetti con ipertensionedi età uguale o superiore a 20 anni
per Area e Sesso nel 2000 e nel 2025
0
2040
60
80
100
120
140
160
180
0
20
40
60
80100
120
140
160
180 Uomini
Donne
1279 Z
20002000
20252025
Nu
mer
o di
sog
gett
i con
iper
ten
sion
e (m
ilion
i)
India
116.2123.3
40.652.5
60.4 57.8 60.054.3
35.9 37.9
98.583.1
38.433.0 38.2 41.6
972 milioni(333 + 639)
147.9161.8
44.0
59.7
107.3106.2 102.198.5
72.280.4
151.7147.5
67.362.1
73.6 77.1
1.56 miliardi
Kearney et al Lancet 2005;365:217-23
Paesi del mercato
comune
EconomieEx-socia-
liste
AmericaLatina e
PaesiCaraibici
MedioOriente
Cina Altre isole ealtri paesiasiatici
AfricaSub-saha-
riana
Globale (paesiSviluppati e
In via di sviluppo)
2231 Mo2231 Mo
Hypertension Prevalences in 6 European and 2 North American Hypertension Prevalences in 6 European and 2 North American Countries, Men and Women Combined, by Age GroupCountries, Men and Women Combined, by Age Group
WolfWolf--Maier et al., JAMA 2003; 289: 2303Maier et al., JAMA 2003; 289: 2303--23692369
35-44 45-54 55-64 65-74Age (years)
0
10
20
30
40
50
60
70
80
90Hypertension prevalence (%)
Germany England Finland Sweden Italy Spain Canada United States
EtEtàà a a rischio rischio
(aa)(aa)
MortalitMortalitàà per Cardiopatia Ischemicaper Cardiopatia IschemicaRischio in Ogni Decade di EtRischio in Ogni Decade di Etàà, vs la PA usuale all, vs la PA usuale all’’Inizio di Ogni DecadeInizio di Ogni Decade
256256
128128
6464
3232
1616
88
44
22
11
120120 140140 160160 180180
256256
128128
6464
3232
1616
88
44
22
11
7070 8080 9090 110110100100
8080--8989
7070--7979
6060--6969
5050--5959
8080--8989
7070--7979
6060--6969
5050--5959
4040--4949 4040--4949
Pressione Arteriosa SistolicaPressione Arteriosa SistolicaPressione Arteriosa Sistolica Pressione Arteriosa DiastolicaPressione Arteriosa DiastolicaPressione Arteriosa Diastolica
PAS usuale (mmHg)PAS usuale (mmHg) PAD usuale (mmHg)PAD usuale (mmHg)
EtEtàà a a rischio rischio
(aa)(aa)
Mor
talit
Mor
talit
ààpe
r ca
rdio
patia
isch
emic
ape
r ca
rdio
patia
isch
emic
a(r
sich
io a
ssol
uto
e IC
95%
)(r
sich
io a
ssol
uto
e IC
95%
)
Prospective Studies Collaboration, Lancet 2002; 360: 1903Prospective Studies Collaboration, Lancet 2002; 360: 1903--1313709 Mo709 Mo
MortalitMortalitàà per Strokeper StrokeRischio in Ogni Decade di EtRischio in Ogni Decade di Etàà, vs la PA usuale all, vs la PA usuale all’’Inizio di Ogni DecadeInizio di Ogni Decade
Pressione Arteriosa SistolicaPressione Arteriosa SistolicaPressione Arteriosa Sistolica Pressione Arteriosa DiastolicaPressione Arteriosa DiastolicaPressione Arteriosa Diastolica
256256
128128
6464
3232
1616
88
44
22
11
120120 140140 160160 180180PAS usuale (mmHg)PAS usuale (mmHg)
Mor
talit
Mor
talit
ààpe
r st
roke
per
stro
ke(r
sich
io a
ssol
uto
e IC
95%
)(r
sich
io a
ssol
uto
e IC
95%
)
256256
128128
6464
3232
1616
88
44
22
11
7070 8080 9090 110110PAD usuale (mmHg)PAD usuale (mmHg)
100100
EtEtàà a a rischio rischio
(aa)(aa)
8080--8989
7070--7979
6060--6969
5050--5959
8080--8989
7070--7979
6060--6969
5050--5959
EtEtàà a a rischio rischio
(aa)(aa)
Prospective Studies Collaboration, Lancet 2002; 360: 1903Prospective Studies Collaboration, Lancet 2002; 360: 1903--1313708 Mo708 Mo
2232 Mo2232 Mo
Hypertension Prevalence vs Stroke Mortality in 6 European Hypertension Prevalence vs Stroke Mortality in 6 European and 2 North American Countries, Men and Women Combinedand 2 North American Countries, Men and Women Combined
10 20 30 40 50 60 70Hypertension prevalence (%)
10
20
30
40
50
60Mortality per 100 000 inhabitants
FinlandFinland
GermanyGermany
SpainSpain
EnglandEnglandItalyItaly
SwedenSwedenUnited StatesUnited States
CanadaCanada
WolfWolf--Maier et al., JAMA 2003; 289: 2303Maier et al., JAMA 2003; 289: 2303--23692369
1500 Mo1500 Mo
Cumulative Incidence of ESRD according to Cumulative Incidence of ESRD according to the 6 Blood Pressure Categoriesthe 6 Blood Pressure Categories
Tozawa M et al., Hypertension 2003; 41: 1341Tozawa M et al., Hypertension 2003; 41: 1341--13451345
NormalNormal
2.02.0
1.51.5
1.01.0
0.50.5
0.00.0
2.02.0
1.51.5
1.01.0
0.50.5
0.00.000 44 88 1212 1616
FollowFollow--up time since screening (years)up time since screening (years)
00 44 88 1212 1616
Cum
ulat
ive
inci
denc
e of
ESR
D (%
)C
umul
ativ
e in
cide
nce
of E
SRD
(%)
Severe HTSevere HT
Moderate HTModerate HT
Mild HTMild HT
HighHigh--normalnormal
NormalNormal
OptimalOptimal
Severe HTSevere HT
Moderate HTModerate HT
Mild HTMild HT
HighHigh--normalnormal
OptimalOptimal
MenMen(n = 46881)(n = 46881)
WomenWomen(n = 51878)(n = 51878)
0
10
20
30
40
50
60
1694 Mo1694 Mo Anakevar MS et al., NEJM 2004; 351: 1285Anakevar MS et al., NEJM 2004; 351: 1285--12951295
Estimates of the Rates of Death at Three Years from Estimates of the Rates of Death at Three Years from Cardiovascular CausesCardiovascular Causes
Est
imat
ed e
vent
rat
e (%
)E
stim
ated
eve
nt r
ate
(%)
Death fromDeath fromCV causesCV causes
ReinfarctionReinfarction CHFCHF StrokeStroke ResusResus--citationcitation
CompositeCompositeend pointend point
GFR (ml/min)GFR (ml/min)≥≥ 75.075.060.060.0--74.974.945.045.0--59.959.9< 45.0< 45.0
P < 0.001P < 0.001
2230 Mo2230 Mo
Hypertension Control for Mean and Women,Hypertension Control for Mean and Women,by Age Group and Country: 140/90 mmHgby Age Group and Country: 140/90 mmHg
Hypertension 2004; 43: 10Hypertension 2004; 43: 10--1717
MenMenMen WomenWomenWomen
0
10
20
30
40
50
60
70
80
90
100
35 - <45 45 - <55 55 - <65 65 - <75
USASpainEnglandGermanyItalyCanadaSweden
Hyp
erte
nsio
n co
ntro
l (%
)H
yper
tens
ion
cont
rol (
%)
Age (years)Age (years)
0
10
20
30
40
50
60
70
80
90
100
35 - <45 45 - <55 55 - <65 65 - <75
USASpainEnglandGermanyItalyCanadaSweden
Age (years)Age (years)
Volpe, J Hypertens 2007
Distribuzione dei valori di pressione arteriosa in 9 studi condotti in Italia su
40.829 ipertesi trattati
Ottimale(<120/80 mmHg)
Normale(120-129/80-84
mmHg)
Normale-alta(130-139/80-85
mmHg)
40
35
30
25
20
15
10
5
0Grado 1
(140-159/90-99 mmHg)
Grado 2 o 3(>160/>100
mmHg)
ISH(>140/<90
mmHg)
4,5
9,2 8,3
39,0
32,6
5,1
Per
cen
tual
e di
paz
ien
ti (
%)
n=1831 n=3739 n=3374 n=15.904 n=13.297 n=2081
Volpe, J Hypertens 2007
Prevalenza dei fattori di rischio cardiovascolare in 15 studi condotti in Italia su 52.715 ipertesi
trattati e non trattati
Fumo Ipercolesterolemia Sovrappeso o obesità
60
50
40
30
20
10
0Diabete mellito
28,7
55,9
36,4
15,0
Per
cen
tual
e di
paz
ien
ti (
%)
n=15.144 n=29.473 n=19.162 n=7903
2220 Mo2220 Mo
Global Cardiovascular Risk Stratification according to ESH/ESCGlobal Cardiovascular Risk Stratification according to ESH/ESC
Volpe M et al., J Hypertens 2007; 25: 1491Volpe M et al., J Hypertens 2007; 25: 1491--14981498
Moderate riskModerate risk(n = 12819)(n = 12819)
Low riskLow risk(n = 8782)(n = 8782)
Very high riskVery high risk(n = 4787)(n = 4787)
High riskHigh risk(n = 11416)(n = 11416)
33.9%
30.2%12.7%12.7%
23.2%
Probability of Survival in HT vs ControlProbability of Survival in HT vs ControlProbability of Survival in HT vs Control
6138 M6138 M
MalesMalesMales
FemalesFemalesFemales
Probability of Probability of survivalsurvival
ReductionReduction(years)(years)
Probability of Probability of survivalsurvival
ReductionReduction(years)(years)
Probability of Probability of survivalsurvival
ReductionReduction(years)(years)
35 years35 years35 years 45 years45 years45 years 55 years55 years55 years
41.5
37.5
32.5
25
43.5
40.5
36.5
31.5
32
29
26
20.5
37
35
32
28.5
23.5
22.5
19.5
17.5
27.5
27
24.5
23.5
11
44
66
0.50.5
33
44
11
66
11.511.5
22
55
8.58.5
44
99
16.516.5
33
77
1212
Normal BPNormal BP
130/90130/90
140/95140/95
150/100150/100
Normal BPNormal BP
130/90130/90
140/95140/95
150/100150/100
779 Mo779 Mo
Effect of AntEffect of Ant--HT Treatment on Risk Reduction HT Treatment on Risk Reduction of CV Diseasesof CV Diseases
Data from 17 studies, 48.000 ptsData from 17 studies, 48.000 pts
-60
-50
-40
-30
-20
-10
0
-60
-50
-40
-30
-20
-10
0Risk ReductionRisk Reduction
(%)(%)
HeartHeartfailurefailure
Fatal/nonfatalFatal/nonfatalstrokesstrokes
CVDCVDdeathsdeaths
Fatal/nonfatalFatal/nonfatalCHD eventsCHD events
-52--5252
-38--3838
-21--2121-16--1616
6398 M6398 M
1.501.50
1.251.25
1.001.00
0.750.75
0.500.50
0.250.25
1.501.50
1.251.25
1.001.00
0.750.75
0.500.50
0.250.25
1.501.50
1.251.25
1.001.00
0.750.75
0.500.50
0.250.25
1.501.50
1.251.25
1.001.00
0.750.75
0.500.50
0.250.25
1.501.50
1.251.25
1.001.00
0.750.75
0.500.50
0.250.25
1.501.50
1.251.25
1.001.00
0.750.75
0.500.50
0.250.25
SBP difference between randomized groups (mmHg)SBP difference between randomized groups (mmHg)
Relative risk of outcome eventRelative risk of outcome event
StrokeStroke Major CVDMajor CVD CHDCHD
CVD deathCVD death
Heart failureHeart failure Total mortalityTotal mortality
-10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4
-10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4
-10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4
-10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4
BP Lowering Coll TrialistsBP Lowering Coll Trialists’’ Group 2003Group 2003
754 Mo754 Mo
Estimated Effect of a 12 mmHg Reduction in SBP over 10 Years Estimated Effect of a 12 mmHg Reduction in SBP over 10 Years on the Numberon the Number--NeededNeeded--toto--Treat to Prevent a Cardiovascular DeathTreat to Prevent a Cardiovascular Death
Ogden LG et al., Hypertension 2000; 35: 539Ogden LG et al., Hypertension 2000; 35: 539
SBP/DBP (mmHg)SBP/DBP (mmHg)
130130--139 / 85139 / 85--8989
140140--159 / 90159 / 90--9999
>> 160 / 160 / >> 100100
Risk Group ARisk Group A
486486
273273
3434
Risk Group BRisk Group B
3636
2727
1212
Risk Group CRisk Group C
2121
1818
1111
753 Mo753 Mo
Estimated Effect of a 12 mmHg Reduction in SBP over 10 Years Estimated Effect of a 12 mmHg Reduction in SBP over 10 Years on the Numberon the Number--NeededNeeded--toto--Treat to Prevent a Cardiovascular EventTreat to Prevent a Cardiovascular Event
Ogden LG et al., Hypertension 2000; 35: 539Ogden LG et al., Hypertension 2000; 35: 539
SBP/DBP (mmHg)SBP/DBP (mmHg)
130130--139 / 85139 / 85--8989
140140--159 / 90159 / 90--9999
>> 160 / 160 / >> 100100
Risk Group ARisk Group A
2525
2020
1010
Risk Group BRisk Group B
1313
1111
77
Risk Group CRisk Group C
1010
99
88
2221 Mo2221 Mo
Relative Frequencies of Patient Adherence to AHTRelative Frequencies of Patient Adherence to AHTat Baseline and during Followat Baseline and during Follow--upup
Mazzaglia G et al., Circulation 2009; 120: 1598Mazzaglia G et al., Circulation 2009; 120: 1598--16051605
1 2 3 4 5 6 7 8 9 10 11 12 0
20
40
60
80
100
High (n = 1516) Intermediate (n = 7624) Low (n = 9666)
Rel
ativ
e fr
eque
ncie
s (%
)R
elat
ive
freq
uenc
ies (
%)
Time units (6 months)Time units (6 months)
2222 Mo2222 Mo
Relationship between the Adherence to AHT and CV EventsRelationship between the Adherence to AHT and CV Events
Mazzaglia G et al., Circulation 2009; 120: 1598Mazzaglia G et al., Circulation 2009; 120: 1598--16051605
AdherenceAdherence
Low (< 40%)Low (< 40%)
Intermediate (40% to 79%)Intermediate (40% to 79%)
High (High (≥≥ 80%)80%)
HRHR
1.001.00
0.860.86
0.620.62
PP
0.1090.109
0.0320.032
2258 Mo2258 Mo
I I NumeriNumeri delldell’’IpertensioneIpertensione ArteriosaArteriosa a a LivelloLivelloPlanetarioPlanetario
7.6 7.6 milionimilioni didi mortimorti premature / anno (13.6% del premature / anno (13.6% del totaletotale))
92 92 milionimilioni didi annianni didi disabilitdisabilitàà (6.0% del (6.0% del totaletotale))
54% 54% deglidegli ictus, 47% ictus, 47% delledelle cardiopatiacardiopatia ischemicheischemiche
80% 80% didi questiquesti eventieventi neinei paesipaesi non non industrializzatiindustrializzati
70 70 miliardimiliardi didi dollaridollari allall’’annoanno per per ll’’insufficienteinsufficiente controllocontrollo della della pressionepressione (10% della (10% della spesaspesa mondialemondiale annuaannua per la salute)per la salute)
1000 1000 miliardimiliardi didi dollaridollari: : proiezioneproiezione deidei costicosti direttidiretti neinei prossimiprossimidiecidieci annianni
3600 3600 miliardimiliardi didi costicosti indirettiindiretti / anno/ anno