Visión multidisciplinar del control de HTA 23/11/16 18:30h Casa del Corazón, Madrid http://controlhta.secardiologia.es #controlHTA Paciente con insuficiencia cardiaca y HTA Dr. Domingo Marzal Martín, Complejo Hospitalario de Mérida (Badajoz) @domingomarzal

1. Madrid, noviembre 2016
Domingo Marzal Martín
Visión multidisciplinar del control de la HTA
HTA & INSUFICIENCIA CARDIACA

2. Bhatia RS, et al. N Engl J Med. 2006;355:260-9
Heart failure
risks factors

3. Farmer C, et al. BMJ. 2016;354:i4843
Multimorbidity

4. SPRINT Investigators. N Engl J Med. 2015;373:2103-16

5. Vidal-Petiot E, et al. Lancet 2016;388:p2142–52
Systolic blood pressure Diastolic blood pressure
CV death, MI or stroke

6. Systolic blood pressure
Diastolic blood pressure
Vidal-Petiot E, et al. Lancet 2016;388:p2142–52
Hospital admission
for heart failure

7. Heart Failure
HR 0.36 (0.22-0.58)
P<0.001
Beckett NS, et al. N Engl J Med. 2008;358:1887-98
Death from Any Cause
HR 0.79 (0.65-0.95)
P=0.02

8. <140/90 mmHg
≈130/80 mmHg
Ponikowski P, et al. Eur Heart J. 2016;37:2129-200

9. Turnbull F, et al. Lancet 2003;362:1527–35

10. Turnbull F, et al. Lancet 2003;362:1527–35

11. Turnbull F, et al. Lancet 2003;362:1527–35

12. HFrEF vs. HFpEF

13. HFrEF

14. Ponikowski P, et al. Eur Heart J. 2016;37:2129-200
Therapeutic algorithm HFrEF
symptomatic (NYHA Class II-IV)

15. Ponikowski P, et al. Eur Heart J. 2016;37:2129-200
ACE inhibitors
Study Drug Symptoms Results (RRR)
CONSENSUS
N Engl J Med. 1987;316:1429-35
Enalaprilo Severe Mortality 27%
SOLVD
N Engl J Med. 1991;325(5):293-302
Enalaprilo Mild-
moderate
Mortality 16%
Hospitalization 26%
SOLVD Prevention
Trial
N Engl J Med. 1992;327:685-91
Captoprilo
Asymptomatic
post-MI
Mortality/
HF hospitalization 20%
SAVE
N Engl J Med. 1992;327:669-77
Captoprilo
Mortality 26%
Mortality/
HF hospitalization 27%
AIRE
Lancet. 1993;342:821-8
Ramiprilo
TRACE
N Engl J Med. 1995;333:1670-6
Trandolaprilo

16. Ponikowski P, et al. Eur Heart J. 2016;37:2129-200
Beta-blockers
Study Drug Symptoms Results
(RRR – first year treatment)
CIBIS II
Lancet. 1999;353:9-13
Bisoprolol
Mild-
moderate Mortality 34%
HF hospitalization 28-36%
MERIT-HF
Lancet. 1999;353:2001-7
Metoprolol CR/XL
COPERNICUS
Circulation. 2002;106:2194-9
Carvedilol
Severe
>90% patients under treated with ACEI or ARB

17. Ponikowski P, et al. Eur Heart J. 2016;37:2129-200
aPitt B, et al. N Engl J Med. 1999;341:709-17
bZannad F, et al. N Engl J Med. 2011;364:11-21
HR 0.70 (0.60-0.82)
P<0.001
Survivalprobability
Spironolactone
Placebo
1,00
0,40
0,90
0,80
0,70
0,60
0,50
0 6 12 18 24 30 36
Months
RALESa
100
0
60
50
40
30
20
10
0 1 2 3
Eplerenone
Placebo
Years
CVmortalityor
HFhospitalization(%)
EMPHASIS-HFb
HR 0,63 (0,54-0,74)
P<0,0001

18. HF Guideline ESC 2016
I
Class
A
Level
Marzal D; et al. Proceso Asistencial Simplificado IC SEC 2016

19. Marzal D; et al. Proceso Asistencial Simplificado IC SEC 2016
HF Guideline ESC 2016
I
Class
C
Level

20. Marzal D; et al. Proceso Asistencial Simplificado IC SEC 2016HF Guideline ESC 2016
I
Class
A
Level

21. HFpEF

22. Yancy CW, et al. J Am Coll Cardiol. 2013;62:e147-239

23. Ponikowski P, et al. Eur Heart J. 2016;37:2129-200
Treatment
HFpEF & HFmrEF

24. Marzal D; et al. Proceso Asistencial Simplificado IC SEC 2016

25. Ponikowski P, et al. Eur Heart J. 2016;37:2129-200
Recommendations for the treatment of hypertension
in symptomatic (NYHA Class II-IV) HFrEF

26. Outcomes trials in HFpEF
HR=0.95 (0.86-1.05)
P=0.35
I-PRESERVEc
Months
Primaryoutcome(%)
CHARM-Preserveda
HR=0.89 (0.77-1.03)
P=0.118
CVdeathor
admissionforCHF(%)
Years
Deathor
HFhospitalization(%)
Years
HR=0.92 (0.70-1.21)
P=0.545
PEP-CHFb
aYusuf S, et al. Lancet 2003;362:777–81
bCleland JG, et al. Eur Heart J. 2006;27:2338-45
cMassie BM, et al. N Engl J Med 2008;359:2456-67
dPitt B, et al. N Engl J Med. 2014;370:1383-92
Spironolactone
Placebo
HR=0.89 (0.77–1.04)
P=0.138
CV death, HF hospitalization
or aborted cardiac arrest
TOPCATd

27. Spironolactone
Placebo
HR=0.89 (0.77–1.04)
P=0.138
351/1723 (20.4%)
320/1722 (18.6%)
CV death, HF hospitalization
or aborted cardiac arrest
Pitt B, et al. N Engl J Med. 2014;370:1383-92
TOPCAT

28. Spironolactone
Placebo
HR=0.83 (0.69–0.99)
P=0.042
245/1723 (14.2%)
206/1722 (12.0%)
Heart failure hospitalization
Pitt B, et al. N Engl J Med. 2014;370:1383-92
TOPCAT

29. Pitt B, et al. N Engl J Med. 2014;370:1383-92
P interaction=0.122
US, Canada, Argentina, Brazil
HR=0.82 (0.69-0.98)
Russia, Rep Georgia
HR=1.10 (0.79-1.51)
Placebo 31.8%
Placebo 8.4%
Exploratory (post-hoc)
CV death, HF hospitalization or aborted cardiac arrest
Spironolactone
Placebo
TOPCAT

30. Kosmala, W. et al. J Am Coll Cardiol. 2016;68:1823-34
STRUCTURE trial

31. Phenotype-specific
HFpEF
Shah SJ, et al. Circulation. 2016;134:73-90

32. Shah SJ, et al. Circulation. 2016;134:73-90

33. Shah SJ, et al. Circulation. 2016;134:73-90

34. take home messages

35. gracias por vuestra atención
domingo.marzal@secardiologia.es
@domingomarzal