INNOVATIONS IN CARDIOVASCULAR RISK IN THE LAST YEAR. A EUROPEAN PERSPECTIVE Vicente Bertomeu Martínez Head of Cardiology. Hospital Universitario San Juan de Alicante (Spain) Prof. of Cardiology UCAM. Director International Institute of Cardiology President Spanish Society of Cardiology The FL Chapter ACC Annual Meeting Orlando, August 17, 2013
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INNOVATIONS IN CARDIOVASCULAR RISK IN THE LAST YEAR. A EUROPEAN PERSPECTIVE
INNOVATIONS IN CARDIOVASCULAR RISK IN THE LAST YEAR. A EUROPEAN PERSPECTIVE. The FL Chapter ACC Annual Meeting Orlando, August 17, 2013. Vicente Bertomeu Martínez Head of Cardiology. Hospital Universitario San Juan de Alicante (Spain) - PowerPoint PPT Presentation
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INNOVATIONS IN CARDIOVASCULAR RISK IN THE LAST YEAR.
A EUROPEAN PERSPECTIVE
Vicente Bertomeu MartínezHead of Cardiology. Hospital Universitario San Juan de Alicante (Spain)Prof. of Cardiology UCAM. Director International Institute of CardiologyPresident Spanish Society of Cardiology
The FL Chapter ACC Annual MeetingOrlando, August 17, 2013
VBM 2013
Decrease in deaths from coronary heart disease attributed to treatments versus prevention
Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug ChoicesInitial Drug Choices
Drug(s) for the compelling Drug(s) for the compelling indications indications
Other antihypertensive drugs Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as (diuretics, ACEI, ARB, BB, CCB) as
needed. needed.
With Compelling With Compelling IndicationsIndications
Lifestyle ModificationsLifestyle Modifications
Stage 2 HypertensionStage 2 Hypertension (SBP (SBP >>160 or DBP 160 or DBP >>100 m100 mmHg) mHg)
2-drug combination for most (usually 2-drug combination for most (usually thiazide-type diuretic and thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)ACEI, or ARB, or BB, or CCB)
Stage 1 HypertensionStage 1 Hypertension(SBP 140(SBP 140–159 or DBP 90–99 mmHg)–159 or DBP 90–99 mmHg)
Thiazide-type diuretics for most. Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, May consider ACEI, ARB, BB, CCB,
or combination.or combination.
Without Compelling Without Compelling IndicationsIndications
Not at Goal Not at Goal Blood PressureBlood Pressure
Optimize dosages or add additional drugs Optimize dosages or add additional drugs until goal blood pressure is achieved.until goal blood pressure is achieved.
Consider consultation with hypertension specialist.Consider consultation with hypertension specialist.
JNC VII: Algorithm for Treatment of HypertensionJNC VII: Algorithm for Treatment of Hypertension
VBM 2013
Stratification of total CV risk in categories of Stratification of total CV risk in categories of low, moderate, high and very high risklow, moderate, high and very high risk
Stratification of total CV risk in categories of Stratification of total CV risk in categories of low, moderate, high and very high risklow, moderate, high and very high risk
140/90 mmHg o 140/90 mmHg o cifras inferiores si son cifras inferiores si son toleradastoleradas, en todos los hipertensos., en todos los hipertensos.
< 130/80 mmHg en < 130/80 mmHg en diabéticos y diabéticos y pacientes de alto ó muy alto riesgo:pacientes de alto ó muy alto riesgo: IctusIctus Enf. CoronariaEnf. Coronaria Enfermedad Renal CrónicaEnfermedad Renal Crónica ProteinuriaProteinuria
J Hypertens 2007; 25: 1.105-1.187VBM 2013
Adjusted risk of outcome events by achieved SBP divided into deciles. ONTARJET
Green continuous line: Preferred Green dashed line: Usseful (with limitations)Black dashed line: Posible but less testedRed continuous line: Not recomended
VBM 2013
Strategies in Resistant HypertensiónStrategies in Resistant HypertensiónStrategies in Resistant HypertensiónStrategies in Resistant Hypertensión
• Parameters to be measured: CT, LDL, TG y HDL. • Main objective: LDL.
• Very high-risk patients: <70 mg/dl (level of evidence in IA) .• High-risk patients: <100 mg/dl (IIaA).• Moderate-risk patients: <115 mg/dl (IIaC). Reduction of at
least 50% of basal levels
VBM 2013
• Statins are the most
effective drugs for the
lowering of total
cholesterol and LDL.
•For every ↓ of 40 mg/dl
of LDL the morbidity and
mortality levels are
reduced by 22%.
VBM 2012
N Engl J Med. 2011 Nov 15.VBM 2013
The addition of the combination of nicotinic acid of modified release and laropiprant to the treatment of statins produced no additional significant reduction in the risk of combined deaths from coronary heart disease, non-fatal heart failures, ictus or revascularizations when compared to statin therapy. There was also a statistically significant increase in the incidence of some types of non-fatal serious adverse events in the group that received nicotinic acid of modified release and laropiprant.
MSD recommends that doctors stop prescribing TREDAPTIVE. MSD also recommends that, in due course, doctors review the treatment plans of patients that are taking TREDAPTIVE stopping treatment with TREDAPTIVE
About the HPS2-THRIVE trial
VBM 2013
Kastelein J et al. N Engl J Med 2008;358:1431-1443 Taylor A et al. N Engl J Med 2009;361:2113-2122
Intima-Media Thickness of the Carotid Artery during 24 and 14 Months of Therapy
ENHANCE-Trial
ARBITER-6 HALTS
VBM 2011
The results of the IMPROVIT trial which will be available in 2015, should finally put an end to this problem.
Adapted from Rosensen RS. Exp Opin Emerg Drugs 2004;9(2):269-279
LaRosa JC et al. N Engl J Med 2005;352:1425-1435
LDL-C mg/dL (mmol/L)
WOSCOPS – Placebo
AFCAPS - Placebo
ASCOT - PlaceboAFCAPS - Rx WOSCOPS - Rx
ASCOT - Rx
4S - Rx
HPS - Placebo
LIPID - Rx
4S - Placebo
CARE - Rx
LIPID - Placebo
CARE - Placebo
HPS - Rx
0
5
10
15
20
25
30
40(1.0)
60(1.6)
80(2.1)
100(2.6)
120(3.1)
140(3.6)
160(4.1)
180(4.7)
Rate
of
even
ts (
%)
6
Secondary prevention
Primary prevention
200(5.2)
PROVE-IT - PRA
PROVE-IT – ATV
TNT – ATV10
TNT – ATV80
Level of LDL-C and CV events
Lower is Better ???
CORONA - RxCORONA - Placebo
VBM 2012
Adapted from Rosensen RS. Exp Opin Emerg Drugs 2004;9(2):269-279
LaRosa JC et al. N Engl J Med 2005;352:1425-1435
LDL-C mg/dL (mmol/L)
WOSCOPS – Placebo
AFCAPS - Placebo
ASCOT - PlaceboAFCAPS - Rx WOSCOPS - Rx
ASCOT - Rx
4S - Rx
HPS - Placebo
LIPID - Rx
4S - Placebo
CARE - Rx
LIPID - Placebo
CARE - Placebo
HPS - Rx
0
5
10
15
20
25
30
40(1.0)
60(1.6)
80(2.1)
100(2.6)
120(3.1)
140(3.6)
160(4.1)
180(4.7)
Rate
of
even
ts (
%)
6
Secondary prevention
Primary prevention
200(5.2)
PROVE-IT - PRA
PROVE-IT – ATV
TNT – ATV10
TNT – ATV80
Level of LDL-C and CV events
CORONA - RxCORONA - Placebo
VBM 2012
HK Lee et al. Benefit of early statin therapy in patients with acute myocardial infarction who have extremely low
low-density lipoprotein cholesterol. J Am Coll Cardiol 2011;58:1664-1671.
•Patients post-STEMI
with LDL <70 mg/dl.
Patients receiving statins, despite having a low LDL level, had
lower rates of major cardiac events
VBM 2012
Most probably the benefits lies in the use of statinand not in the level of LDL
Cordero A, Bertomeu V, et al. Rev Esp Cardiol 2013
Benefits of statin therapy in patients with acute coronary syndrome
Cordero A, Bertomeu V, et al. Med Clin (Barc) 2012; 138:422-28 VBM 20123
A. Cordero
Risk Profile
Non Smokers Exsmokers Smokers
130
140
150
160
170
GR
AC
E s
core
]
]
]
150,3 (30,6)
146,2 (30,9)
132,1 (30,1)
p<0,01
Cordero A, Bertomeu v, et al. Med Clin (Barc) 2012; 138:422-28 VBM 2013
A. Cordero
Risk Profile
]
]
]
80,00
85,00
90,00
Non smokers Exsmokers Smokerss
86,1 (24,0)85,2 (24,0)
87,1 (25,0)
p=0,3
GR
AC
E s
core
Wit
ho
ut
age
Cordero A, Bertomeu V, et al. Med Clin (Barc) 2012; 138:422-28 VBM 2013
The risk in smokers is the same as that ofnon smokers who are 10 years older
Trends in Mortality From Myocardial Infarction. A Comparative Study Between Spain and the United States: 1990-2006
Domingo Orozco-Beltrana, Richard S. Cooperb, Vicente Gil-Guillena, Vicente Bertomeu-
Martinezc, Salvador Pita-Fernandezd, Ramón Durazo-Arvizub, Concepción Carratala-Munueraa, Luis Cea-Calvoa, Vicente Bertomeu-Gonzalezc,, Teresa Seoane-Pilladoc, Luis E.
Rosadoe
Rev Esp Cardiol. 2012;65:1079-85VBM 2013
USA shows better results. Probably better implementations of Therapeutic Procedures and to having an effective and preventive policy against risk factors