KHỞI TRỊ TĂNG HA Ở NGƯỜI CAO TUỔI: CHỨNG CỨ LIÊN QUAN ĐẾN THUỐC LỢI TiỂU PGS TS Trương Quang Bình ĐHYD TP HCM Systolic BP: highly predictive of stroke risk Stroke mortality* Age at risk 256 80-89 y 128 70-79 y 64 60-69 y 32 50-59 16 120 * Floating absolute risk and 95% confidence interval SBP, systolic blood pressure Lewington S et al Lancet 2002;360:1903-1913 140 160 180 Usual systolic BP (mm Hg) Hypertension sub-type According to Age Franklin SS, et al Circulation 1997;96: 308-15 Reflected waves due to stiffer arteries from periphery increase pulse wave velocity & Systolic BP O’Rourke M Hypertension 1995;26:2-9 Older patients have a low level of renin activity Supine plasma renin activity (PRA) and aldosterone plasma level as a function of age in healthy normotensive people receiving an ad libitum sodium diet Belmin et al Drugs Aging 1994;5(5):391-400 Tiến triển tăng HA B Williams 2007 Number Amlodipine has Shown CV Protective Efficacy in Landmark Studies PREVENT1 825 CAD patients (≥ 30%); multicentre, randomized, placebo-controlled CAMELOT2 1,991 CAD patients (≥ 20%); double-blind, randomized study vs placebo and enalapril 20 mg ASCOT-BPLA/CAFE3,4 19,257 HTN patients; multicentre, randomized, prospective study vs atenolol ALLHAT5 18,102 HTN patients; multicentre, randomized, prospective study vs lisinopril Primary outcome: no difference in mean 3-y coronary angiographic changes vs placebo 35% ↓hospitalization for heart failure + angina 33% ↓revascularization procedures Primary outcome: 30%↓in CV events vs placebo 41% ↓hospitalization for angina 27% ↓coronary revascularization Primary outcome: 10%↓in non-fatal MI and fatal CHD 16% ↓total CV events and procedures 30% ↓new-onset diabetes 27% ↓stroke 11% ↓all-cause mortality 4.3 mmHg ↓central aortic pressure Primary outcome: no difference in composite of fatal CHD and non-fatal MI vs lisinopril 6% ↓combined CVD 23% ↓stroke Pitt et al Circulation 2000;102:1503–1510; Nissen et al JAMA 2004;292:2217–2226; Dahlof et al Lancet 2005;366:895–906; Williams et al Circulation 2006;113:1213 –1225; Leenen et al Hypertension.2006;48:374–384 A = ACE-inh or ARB, C = CCB, D = thiazide type diuretic 12 Cumulative Event Rates for All-Cause Mortality by ALLHAT Treatment Group ALLHAT Cumulative Mortality Rate 25 HR (95% CI) p value A/C 0.96 (0.89-1.02) 0.20 L/C 1.00 (0.94-1.08) 0.90 Chlorthalidone Amlodipine Lisinopril 15 05 0 Number at risk: Chlor 15,255 Amlo 9,048 Lisin 9,054 14,933 8,847 8,853 14,564 8,654 8,612 Years to Death 14,077 8,391 8,318 12,480 7,442 7,382 7.185 4,312 4,304 3,523 2,101 2,121 4288 217 144 13 Cumulative Event Rates for Heart Failure by ALLHAT Treatment Group ALLHAT Cumulative CHF Rate 15 HR (95% CI) p value A/C 1.38 (1.25-1.52)