Modulo 1 riesgo cv

Notas del editor

• #3: The prevalence of hypertension increases steadily with age in both genders according to NHANES III estimates for 1988-1994. In this survey, hypertension was defined as an SBP of  140 mm Hg, a DBP of  90 mm Hg, or taking antihypertensive medication. Up to age 34 years of age, hypertension generally affects  10% of the population. By 65 years of age, however, more than 50% of individuals on average are hypertensive. Wolz M, Cutler J, Roccella EJ, et al. Statement from the National High Blood Pressure Education Program: Prevalence of hypertension. Am J Hypertens. 2000;13:103-104.
• #4: The most reliable data on the incidence of high BP across Europe come from the MONICA project, which defined hypertension as systolic pressures of  160 mm Hg. Between 2% (Toulouse, France) and 21% (North Karelia, Finland) of European men aged 35-64 years have hypertension. For European women aged 35-64 years, between 2% (Catalonia, Spain, and Ghent, Belgium) and 17% (East Germany) have hypertension. British Heart Foundation. European Cardiovascular Disease Statistics, 2000 Edn. 2000.
• #15: Observaciones similares fueron hechas en el estudio Framingham sobre la relación entre la hipertensión y la incidencia de eventos vasculares cerebrales. La diferencia del poder patogénico de la hipertensión entre los dos géneros no es tan manifiesta como en el caso de la cardiopatía isquémica, lo que indica que para la génesis de esta última están involucrados otros factores aparte de la elevación de las cifras de presión. Vuelve a apreciarse que cifras limítrofes elevan dos veces y medio el riesgo de EVC en comparación con los sujetos que tienen cifras normales, en ambos géneros y la PA elevada aumenta 8 y 9 veces el riesgo de EVC en mujeres y hombres respectivamente.
• #16: Las observaciones del estudio Framingham demostraron que la incidencia de síndromes coronarios aumenta cuando se comparan sujetos con PA deseable con hipertensos. Nótese que cifras limítrofes de hipertensión casi doblan el riesgo de enfermedad coronaria en hombres y en mujeres y que las cifras elevadas de PA más que triplican este riesgo en los dos géneros. También puede apreciarse que el riesgo de la hipertensión es mucho más manifiesto en los hombres que en las mujeres, aunque este riesgo mayor ya lo tienen con respecto a las mujeres los hombres con PA normal.
• #18: Epidemiologic research has shown that hypertension usually occurs in conjunction with other CV risk factors. Data from the Framingham Study clearly illustrate the co-existence of risk factors in the hypertensive population. In the Framingham population, < 20% of hypertension cases occurred in isolation. Nearly one third of all patients (30% in men and 32% in women) had 3 or more risk factors for CV in addition to hypertension. Kannel WB. Risk stratification in hypertension: new insights from the Framingham Study. Am J Hypertens. 2000;13:3S-10S.
• #20: While the presence of a single CV risk factor can dramatically increase the patient’s risk of CHD, risk factors often do not exist in isolation. Using data from a random sample of Australian men and women, MacMahon and colleagues examined the prevalence of hypercholesterolemia (defined as TC  6.5 mmol/L [  250 mg/dL]) in patients with hypertension (BP  150/  95 mm Hg) or who were taking antihypertensive medication. The incidence of hypercholesterolemia in men and women with hypertension or who were taking antihypertensive medications was significantly higher than that in men and women who did not have elevated BP. In addition, the prevalence of elevated TC:HDL-C ratios was higher among hypertensive men and women than in patients with normal BP. MacMahon M, Macdonald GJ, Blacket RG. Plasma lipoprotein levels in treated and untreated hypertensive men and women: the National Heart Foundation of Australia risk factor prevalence study. Arteriosclerosis. 1985;5:391-396.
• #21: Large epidemiologic studies illustrate the risk associated with hypertension and elevated TC levels. The Framingham Heart Study is a large epidemiologic study initiated in 1949 that examined the impact of cardiovascular (CV) risk factors on CHD in 5209 randomly selected American men and women. At entry, the large majority of patients were free of cardiovascular disease (CVD). A clear, curvilinear relationship was observed between SBP and subsequent development of CVD. A strong relationship between TC levels and the rate of CHD was apparent by the sixth year of follow-up in the Framingham Study. The incidence of CHD in male subjects aged 30-49 years with TC levels of > 7.6 mmol/L (> 295 mg/dL) was approximately 6 times that of subjects with TC levels of between 5.3 and 6.0 mmol/L (205-234 mg/dL). Today’s guidelines for hypertension and lipid management are based largely on data from large epidemiologic trials like the Framingham study. These data have unequivocally shown the benefit of managing these risk factors. Kannel W. Importance of hypertension as a major risk factor in cardiovascular disease. Hypertension: Pathophysiology and Treatment . New York: McGraw-Hill, Inc.; 1977:888-909. Castelli WP. Epidemiology of coronary heart disease: the Framingham Study. Am J Med. 1984;76:4-12.
• #22: Using data from the Multiple Risk Factor Intervention Trial (MRFIT), Neaton and colleagues examined the additive effect of TC levels and SBP on CHD death rates. Note the generally strong, graded relationship between increasing cholesterol levels and CHD death across SBP levels and the generally strong relationship between small increases in SBP and CHD death across TC levels. When risk factors were analyzed together, patients in both the highest TC and the highest SBP quintiles had an approximately 11-fold greater risk of CHD death than patients who were in both the lowest TC and the lowest SBP quintiles. Neaton JD, Wentworth D. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Overall findings and differences by age for 316,099 white men. Multiple Risk Factor Intervention Trial Research Group. Arch Intern Med. 1992;152:56-64.
• #23: Using data from 4483 subjects aged 35-70 years who were participating in a large study of type 2 diabetes, Isomaa and colleagues compared the prevalence of CV risk factors in patients with type 2 diabetes (n = 1697), impaired fasting glucose/impaired glucose tolerance (n = 798), or insulin resistance with normal glucose tolerance (n = 1998). The risk factors evaluated included hypertension, dyslipidemia, obesity, and microalbuminuria. This slide shows the prevalence of dyslipidemia and hypertension among male patients in each of these patient groups. Compared with patients with normal glucose tolerance, the prevalence of dyslipidemia and hypertension increased with increasing glucose intolerance and was approximately 2-fold greater among patients with type 2 diabetes. Isomaa B, Almgren P, Tuomi T, et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care. 2001;24:683-689.
• #24: The interaction of multiple risk factors may lead to multiplicative, rather than merely additive, increases in CV risk. These Venn diagrams depict the increases in risk associated with the presence of multiple CV risk factors in 2 hypothetical 40-year-old male patients, compared with the CVD risk of a 40-year-old male nonsmoker with TC 4.7 mmol/L (185 mg/dL) and SBP 120 mm Hg, who is not glucose intolerant, and who does not have LVH. The Venn diagram on the left illustrates the interaction of risk factors in a patient with moderately elevated TC (5.4 mmol/L [210 mg/dL]), hypertension (SBP 165 mm Hg), and glucose intolerance. While each risk factor alone results in a 1.3- to 1.9-fold increase in CVD risk, the interaction of all 3 risk factors results in a 4.5-fold increase in CVD risk. The Venn diagram on the right shows the interaction of risk factors in a patient with elevated TC (6.1 mmol/L [235 mg/dL]) and severe hypertension (SBP 195 mm Hg) and who smokes. Each individual risk factor results in a 1.7- to 3.0-fold increase in CVD risk. However, the presence of all 3 risk factors results in an 8.7-fold increase in risk. Kannel W. Importance of hypertension as a major risk factor in cardiovascular disease. Hypertension: Pathophysiology and Treatment . New York: McGraw-Hill, Inc.; 1977:888-909.
• #29: The recommendations of the Second Joint Task Force of European and other societies on coronary prevention also recognize the multifactorial nature of CVD risk. The first step toward determining treatment goals and modalities for both hypertension and lipid management is to estimate coronary risk. Factoring SBP, TC, smoking status, and age, this chart is used to estimate absolute 10-year risk of CHD in men in whom symptomatic CHD or other atherosclerotic disease has not developed. A similar, though not identical, chart is used to estimate coronary risk in women. Wood D, De Backer G, Faergeman O, et al. Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on Coronary Prevention. Atherosclerosis. 1998;140:199-270.
• #33: In the Hypertension Optimal Treatment (HOT) study, (n=18,790) hypertensive patients (DBP 100-115 mm Hg) from 26 countries were randomly assigned to 1 of 3 DBP target groups: ≤90 mm Hg, ≤85 mm Hg, and ≤80 mm Hg. The long-acting dihydropyridine CCB felodipine was given as baseline therapy, with the addition of other agents as needed to reach goal. The mean age of the study group was 61.5 years. After a mean of 3.8 years of follow-up, DBP was reduced to 85.2 mm Hg in the group assigned to the ≤90 mm Hg goal, to 83.2 mm Hg in the group assigned to ≤85 mm Hg, and to 81.1 mm Hg in the group assigned to ≤80 mm Hg. Results in the subgroup of 1501 diabetic patients are shown here. The rate of major CV events (fatal/nonfatal MI, fatal/nonfatal stroke, and all other CV deaths) was reduced by approximately 50% in the group assigned a DBP goal ≤80 mm Hg compared with those assigned a goal of ≤90 mm Hg ( p =0.005). The difference between groups remained significant ( p =0.045) when silent MI was included in the analysis (data not shown). The rate of stroke was reduced by 30% and the rate of all MI by 50% in the ≤80 mm Hg group compared with the ≤90 mm Hg group, although these reductions did not achieve statistical significance (data not shown). Hansson L et al. Lancet . 1998;351:1755-1762.
• #34: In the Hypertension Optimal Treatment (HOT) study, (n=18,790) hypertensive patients (DBP 100-115 mm Hg) from 26 countries were randomly assigned to 1 of 3 DBP target groups: ≤90 mm Hg, ≤85 mm Hg, and ≤80 mm Hg. The long-acting dihydropyridine CCB felodipine was given as baseline therapy, with the addition of other agents as needed to reach goal. The mean age of the study group was 61.5 years. After a mean of 3.8 years of follow-up, DBP was reduced to 85.2 mm Hg in the group assigned to the ≤90 mm Hg goal, to 83.2 mm Hg in the group assigned to ≤85 mm Hg, and to 81.1 mm Hg in the group assigned to ≤80 mm Hg. Results in the subgroup of 1501 diabetic patients are shown here. The rate of major CV events (fatal/nonfatal MI, fatal/nonfatal stroke, and all other CV deaths) was reduced by approximately 50% in the group assigned a DBP goal ≤80 mm Hg compared with those assigned a goal of ≤90 mm Hg ( p =0.005). The difference between groups remained significant ( p =0.045) when silent MI was included in the analysis (data not shown). The rate of stroke was reduced by 30% and the rate of all MI by 50% in the ≤80 mm Hg group compared with the ≤90 mm Hg group, although these reductions did not achieve statistical significance (data not shown). Hansson L et al. Lancet . 1998;351:1755-1762.
• #35: In the Hypertension Optimal Treatment (HOT) study, (n=18,790) hypertensive patients (DBP 100-115 mm Hg) from 26 countries were randomly assigned to 1 of 3 DBP target groups: ≤90 mm Hg, ≤85 mm Hg, and ≤80 mm Hg. The long-acting dihydropyridine CCB felodipine was given as baseline therapy, with the addition of other agents as needed to reach goal. The mean age of the study group was 61.5 years. After a mean of 3.8 years of follow-up, DBP was reduced to 85.2 mm Hg in the group assigned to the ≤90 mm Hg goal, to 83.2 mm Hg in the group assigned to ≤85 mm Hg, and to 81.1 mm Hg in the group assigned to ≤80 mm Hg. Results in the subgroup of 1501 diabetic patients are shown here. The rate of major CV events (fatal/nonfatal MI, fatal/nonfatal stroke, and all other CV deaths) was reduced by approximately 50% in the group assigned a DBP goal ≤80 mm Hg compared with those assigned a goal of ≤90 mm Hg ( p =0.005). The difference between groups remained significant ( p =0.045) when silent MI was included in the analysis (data not shown). The rate of stroke was reduced by 30% and the rate of all MI by 50% in the ≤80 mm Hg group compared with the ≤90 mm Hg group, although these reductions did not achieve statistical significance (data not shown). Hansson L et al. Lancet . 1998;351:1755-1762.
• #36: In the Hypertension Optimal Treatment (HOT) study, (n=18,790) hypertensive patients (DBP 100-115 mm Hg) from 26 countries were randomly assigned to 1 of 3 DBP target groups: ≤90 mm Hg, ≤85 mm Hg, and ≤80 mm Hg. The long-acting dihydropyridine CCB felodipine was given as baseline therapy, with the addition of other agents as needed to reach goal. The mean age of the study group was 61.5 years. After a mean of 3.8 years of follow-up, DBP was reduced to 85.2 mm Hg in the group assigned to the ≤90 mm Hg goal, to 83.2 mm Hg in the group assigned to ≤85 mm Hg, and to 81.1 mm Hg in the group assigned to ≤80 mm Hg. Results in the subgroup of 1501 diabetic patients are shown here. The rate of major CV events (fatal/nonfatal MI, fatal/nonfatal stroke, and all other CV deaths) was reduced by approximately 50% in the group assigned a DBP goal ≤80 mm Hg compared with those assigned a goal of ≤90 mm Hg ( p =0.005). The difference between groups remained significant ( p =0.045) when silent MI was included in the analysis (data not shown). The rate of stroke was reduced by 30% and the rate of all MI by 50% in the ≤80 mm Hg group compared with the ≤90 mm Hg group, although these reductions did not achieve statistical significance (data not shown). Hansson L et al. Lancet . 1998;351:1755-1762.