Transcript Efeitos deletérios do LDL oxidado

Estado da arte em 2012
Prof Flávio Danni Fuchs
Professor Associado de Cardiologia, FAMED, UFRGS
Coordenador do INCT-IATS e Estudo PREVER
Pesquisador IA do CNPq
Tratamento não-medicamentoso
Efetividade a longo prazo de abordagens não-medicamentosas
(TOHP-II, Arch Intern Med 1997; 157:657)
130
Control
Weight
Salt
Combined
128
Systolic BP
(mmHg)
126
124
122
120
87
85
Diastolic BP
(mmHg)
83
81
79
Basal
6
18
Months of follow-up
36
Efeitos de dietas hipossódicas na excreção urinária de
sódio (estudos de longa duração)
1 mmol de Na+ = 23 mg
40 mmol = 920 mg ∞ 1 g
Taylor RS, et al. AJH 2011; 24: 843
Efeitos de dietas hipossódicas na PAS
Taylor RS, et al. AJH 2011; 24: 843
Efeitos de dietas hipossódicas na PAD
Taylor RS, et al. AJH 2011; 24: 843
Efeitos de dietas hipossódicas na incidência de DCV
Taylor RS, et al. AJH 2011; 24: 843
Efeitos de dietas hipossódicas na incidência de eventos
cardiovasculares
(He FJ, MacGregor GA. Lancet 2011; 378: 380)
Efetividade da adesão a MEV (23,8 meses)
(Riegel G. AJH 2012; in press)
Recomendações
Delta
Inter-grupos
Favorece
Não-adesão
Favorece
adesão
Dieta hipossódica
Sistólica
5,1 (1,7-8,6)
Diastólica
2,1 (0,2 - 3,9)
Dieta hipocalórica
Sistólica
Diastólica
6,6 (2,9 - 10,2)
2,0 (0,1 - 3,9)
Exercícios
Sistólica
1,6 (-1,7 - 4,9)
Diastólica
0,1 (-1,7 - 1,8)
-5,0
0
5,0
10,0
Delta de PA (mmHg)
In the meantime, it is worthy to present the option to
start low doses of BP agents for individuals who do not
respond to the prescription of lifestyle modification.
BP-lowering drugs: essentials for some patients with
normal BP. (Fuchs FD. Expert Rev Cardiovasc Ther 2004; 2:89-94.)
Condition
Active
treatment
Primary
outcome
RRR (%)
(95% CI)
D. mellitus
Ramipril
MI, stroke or CV death
25 (12 to 36)
Any evidence of Ramipril
atherosclerosis Perindopril
MI, stroke or CV death
MI, CV death, c. arrest
22 (14 to 30)
20 (9 to 29)
MI
Beta-blocker
Recurrent MI
22 (16 to 28)
Stroke
Indapamide
Stroke
plus perindopril
42 (19 to 58)
Not overt HF
Enalapril
CV deaths
12 (-3 to 26)
Overt HF
Enalapril
Captopril
CV deaths
18 (6 to 28)
21 (5 to 35)
Drug treatment among persons without hypertension
Thompson AM, et al. JAMA 2011; 305:913-22.
Drug treatment among persons without hypertension
Thompson AM, et al. JAMA 2011; 305:913-22.
Additional randomized trial data are
necessary to assess these outcomes
in patients without CVD clinical
recommendations.
Tratamento medicamentoso
Diuretics are still essential drugs for hypertension
management, but diuretics with higher potency and
duration of action, such as chlorthalidone, should be
preferred.
Clortalidona bombando
Novas análises do MRFIT - PA
Dorsch MP. Hypertension 2011; 57:689-694
Novas análises do MRFIT - Eventos
Dorsch MP. Hypertension 2011; 57:689-694
Novidades sobre losartana e
parentes
European revised (2009)
Journal of Hypertension. doi:10.1097/HJH.0b013e3281fc975a
ARB and the prevention of atrial fibrillation - I
The GISSI-AF Investigators. N Engl J Med 2009; 360:1606-17.
ARB and the prevention of atrial fibrillation-II
ACTIVE. NEJM 2011; 364:928-38.
INCIDENCE OF MICROALBUMINURIA IN TYPE 1 DIABETES
Mauer M, et al. N Engl J Med 2009;361:40-51.
Placebo
Enalapril
Losartan
6
4
17
0
5
10
15
20
%
ONTARGET – RISCOS DO DUPLO BLOQUEIO
NEJM 2008; 338:b1665.
Risco
ramipril
Revascularização
Risco
associação
1.04 (0.97–1.13)
Insuficiência cardíaca 0.94 (0.83–1.07
Fibrilação atrial
0.96 (0.85–1.07)
Piora função renal
1.33 (1.22–1.44)
Ins renal terminal
1.37 (0.94–1.98)
0,5
1,0
2,0
Efeitos renais em trials recentes
ROADMAP (N Engl J Med 2011; 364:907): the reduction in
glomerular filtration rate was higher in patients
treated with olmesartan instead of placebo (P<0.001).
ACTIVE (N Engl J Med 2011; 364:928): the incidence of renal
dysfunction leading to discontinuation of the drug
almost doubled in patients treated with irbesartan
(0.95%) than placebo (0.53%), P = 0.02.
TRANSCEND (Ann Intern Med 2009; 151:1-10): the
decreasing in glomerular filtration rate was greater
with telmisartan than with placebo (P < 0.001)
E há outras preocupações
STUDY
Control
Outcome
RR
Risk for
control
LIFE
(losartan)
Atenolol
Composite CV
0.76 (0.58–0.98)
VALUE
(valsartan)
Amlodipine
MI
1.19 (1.02-1.38)
ONTARGET
(telmisartan)
Ramipril
Composite CV
1.01 (0.94–1.09)
SCOPE
(candesartan)
Placebo
Composite CV
0.89 (0.76-1.06)
TRANSCEND
(telmisartan)
Placebo
Composite CV
0.92 (0.82-1.05)
PROFESS
(telmisartan)
Placebo
Stroke
0.95 (0.86-1.04)
NAVIGATOR
(valsartan)
Placebo
Composite CV
0.99 (0.86-1.14)
ACTIVE
(irbesartan)
Placebo
Composite CV
0.99 (0.91-1.08)
Placebo
Mortality CV
4.94 (1.43–17.06)
Placebo
Mortality CV
3.36 (0.93-12.07)
ROADMAP
(olmesartan)
ORIENT
(olmesartan)
0.5
Risk for ARB
1.0
1.5
5.0
ARB do not cause myocardial infarction
Messerli FH et al. BMJ 2011; 342:d2234.
ARB do not cause myocardial infarction
Messerli FH. BMJ 2011; 342:d2234.
When