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 2

Efetividade a longo prazo de abordagens não-medicamentosas (TOHP-II, Arch Intern Med 1997; 157:657) Systolic BP (mmHg) Diastolic BP (mmHg) Months of follow-up

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 6,6 (2,9 - 10,2) Diastólica 2,0 (0,1 - 3,9) Exercícios 1,6 (-1,7 - 4,9) Sistólica Diastólica 0,1 (-1,7 - 1,8) -5,0 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. 10

BP-lowering drugs: essentials for some patients with normal BP BP-lowering drugs: essentials for some patients with normal BP. (Fuchs FD. Expert Rev Cardiovasc Ther 2004; 2:89-94.) Condition Active Primary RRR (%) treatment outcome (95% CI) D. mellitus Ramipril MI, stroke or CV death 25 (12 to 36) Any evidence of Ramipril MI, stroke or CV death 22 (14 to 30) atherosclerosis Perindopril MI, CV death, c. arrest 20 (9 to 29) MI Beta-blocker Recurrent MI 22 (16 to 28) Stroke Indapamide Stroke 42 (19 to 58) plus perindopril Not overt HF Enalapril CV deaths 12 (-3 to 26) Overt HF Enalapril CV deaths 18 (6 to 28) Captopril 21 (5 to 35) 11

Drug treatment among persons without hypertension Thompson AM, et al. JAMA 2011; 305:913-22. 12

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. 13

Tratamento medicamentoso 14

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 16 16

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 19

European revised (2009) Journal of Hypertension. doi:10.1097/HJH.0b013e3281fc975a 20

ARB and the prevention of atrial fibrillation - I The GISSI-AF Investigators. N Engl J Med 2009; 360:1606-17. 21

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 INCIDENCE OF MICROALBUMINURIA IN TYPE 1 DIABETES Mauer M, et al. N Engl J Med 2009;361:40-51. 6 4 17 %

ONTARGET – RISCOS DO DUPLO BLOQUEIO NEJM 2008; 338:b1665. ramipril Risco associação Revascularização 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 24

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

0.5 1.0 1.5 5.0 STUDY Control Risk for control Risk for ARB Outcome RR LIFE (losartan) Atenolol Composite CV 0.76 (0.58–0.98) 1.19 (1.02-1.38) VALUE (valsartan) Amlodipine MI 1.01 (0.94–1.09) ONTARGET (telmisartan) Ramipril Composite CV Placebo Composite CV 0.89 (0.76-1.06) SCOPE (candesartan) Placebo Composite CV 0.92 (0.82-1.05) TRANSCEND (telmisartan) PROFESS (telmisartan) Placebo Stroke 0.95 (0.86-1.04) 0.99 (0.86-1.14) NAVIGATOR (valsartan) Placebo Composite CV 0.99 (0.91-1.08) ACTIVE (irbesartan) Placebo Composite CV ROADMAP (olmesartan) Placebo Mortality CV 4.94 (1.43–17.06) ORIENT (olmesartan) Placebo Mortality CV 3.36 (0.93-12.07) 0.5 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