Ipertensione e Rischio Cardiovascolare

Alberto Morganti

U.O. Medicina Generale, Centro Ipertensione ArteriosaOspedale San Giuseppe, Università di Milano

Abuso di sale, Obesità e IpertensioneMinistero della salute

Roma, 14 giugno 2010

Mortalità dovuta ai principali fattori di rischio globale (WHO World Health Report 2002)

Ezzati et al., Lancet 2002

8000

7000

6000

5000

4000

3000

2000

1000

0

Mor

talit

àat

trib

uib

ile (

x 1

00

0) Alta mortalità, Paese in via di sviluppo

Più bassa mortalità, Paese in via di sviluppoPaese industrializzato

Iper

tens

ione

iper

cole

ster

olem

ia

Sess

o no

n pr

otet

to

Elev

ato

BMI

Pollu

zion

e at

mos

feric

a ur

bana

Def

icit

Vit.

A

Inqu

inam

ento

da

part

icol

ari

ambi

enti

di la

voro

Espo

sizi

one

al p

iom

bo

Taba

cco

Peso

infe

riore

alla

nor

ma

Bass

o c

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mo

di f

rutt

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verd

ura

Inat

tività

fisic

a

Acqu

a in

quin

ata

e ca

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ieni

che

Def

icit

di f

erro

Def

icit

di z

inco

Uns

afe

heal

th-c

are

inje

ctio

ns

Fatt

ori d

i ris

chio

oc

cupa

zion

ali

Sost

anze

ill

ecite

Alco

ol

0877 Z

Fum

o in

door

0 5 10 15 20 25

Other CV disease Hypertensive disease Ischaemic heart disease Stroke

2259 Mo2259 Mo

DisabilityDisability--adjusted Life Years (DALYs) Attributable to adjusted Life Years (DALYs) Attributable to High Blood Pressure by Region and Endpoint in 2001High Blood Pressure by Region and Endpoint in 2001

Lawes CMM et al., Lancet 2008; 371: 1513Lawes CMM et al., Lancet 2008; 371: 1513--15181518

Wor

ld B

ank

regi

ons

Wor

ld B

ank

regi

ons

Attributable DALYs (1000000s)Attributable DALYs (1000000s)

East Asia and PacificEast Asia and Pacific

Europe and central AsiaEurope and central Asia

Latin America andLatin America andthe Caribbeanthe Caribbean

Middle East and north AfricaMiddle East and north Africa

South AsiaSouth Asia

SubSub--Saharan AfricaSaharan Africa

HighHigh--income economiesincome economies

Numero di Soggetti con ipertensionedi età uguale o superiore a 20 anni

per Area e Sesso nel 2000 e nel 2025

0

2040

60

80

100

120

140

160

180

0

20

40

60

80100

120

140

160

180 Uomini

Donne

1279 Z

20002000

20252025

Nu

mer

o di

sog

gett

i con

iper

ten

sion

e (m

ilion

i)

India

116.2123.3

40.652.5

60.4 57.8 60.054.3

35.9 37.9

98.583.1

38.433.0 38.2 41.6

972 milioni(333 + 639)

147.9161.8

44.0

59.7

107.3106.2 102.198.5

72.280.4

151.7147.5

67.362.1

73.6 77.1

1.56 miliardi

Kearney et al Lancet 2005;365:217-23

Paesi del mercato

comune

EconomieEx-socia-

liste

AmericaLatina e

PaesiCaraibici

MedioOriente

Cina Altre isole ealtri paesiasiatici

AfricaSub-saha-

riana

Globale (paesiSviluppati e

In via di sviluppo)

2231 Mo2231 Mo

Hypertension Prevalences in 6 European and 2 North American Hypertension Prevalences in 6 European and 2 North American Countries, Men and Women Combined, by Age GroupCountries, Men and Women Combined, by Age Group

WolfWolf--Maier et al., JAMA 2003; 289: 2303Maier et al., JAMA 2003; 289: 2303--23692369

35-44 45-54 55-64 65-74Age (years)

0

10

20

30

40

50

60

70

80

90Hypertension prevalence (%)

Germany England Finland Sweden Italy Spain Canada United States

EtEtàà a a rischio rischio

(aa)(aa)

MortalitMortalitàà per Cardiopatia Ischemicaper Cardiopatia IschemicaRischio in Ogni Decade di EtRischio in Ogni Decade di Etàà, vs la PA usuale all, vs la PA usuale all’’Inizio di Ogni DecadeInizio di Ogni Decade

256256

128128

6464

3232

1616

88

44

22

11

120120 140140 160160 180180

256256

128128

6464

3232

1616

88

44

22

11

7070 8080 9090 110110100100

8080--8989

7070--7979

6060--6969

5050--5959

8080--8989

7070--7979

6060--6969

5050--5959

4040--4949 4040--4949

Pressione Arteriosa SistolicaPressione Arteriosa SistolicaPressione Arteriosa Sistolica Pressione Arteriosa DiastolicaPressione Arteriosa DiastolicaPressione Arteriosa Diastolica

PAS usuale (mmHg)PAS usuale (mmHg) PAD usuale (mmHg)PAD usuale (mmHg)

EtEtàà a a rischio rischio

(aa)(aa)

Mor

talit

Mor

talit

ààpe

r ca

rdio

patia

isch

emic

ape

r ca

rdio

patia

isch

emic

a(r

sich

io a

ssol

uto

e IC

95%

)(r

sich

io a

ssol

uto

e IC

95%

)

Prospective Studies Collaboration, Lancet 2002; 360: 1903Prospective Studies Collaboration, Lancet 2002; 360: 1903--1313709 Mo709 Mo

MortalitMortalitàà per Strokeper StrokeRischio in Ogni Decade di EtRischio in Ogni Decade di Etàà, vs la PA usuale all, vs la PA usuale all’’Inizio di Ogni DecadeInizio di Ogni Decade

Pressione Arteriosa SistolicaPressione Arteriosa SistolicaPressione Arteriosa Sistolica Pressione Arteriosa DiastolicaPressione Arteriosa DiastolicaPressione Arteriosa Diastolica

256256

128128

6464

3232

1616

88

44

22

11

120120 140140 160160 180180PAS usuale (mmHg)PAS usuale (mmHg)

Mor

talit

Mor

talit

ààpe

r st

roke

per

stro

ke(r

sich

io a

ssol

uto

e IC

95%

)(r

sich

io a

ssol

uto

e IC

95%

)

256256

128128

6464

3232

1616

88

44

22

11

7070 8080 9090 110110PAD usuale (mmHg)PAD usuale (mmHg)

100100

EtEtàà a a rischio rischio

(aa)(aa)

8080--8989

7070--7979

6060--6969

5050--5959

8080--8989

7070--7979

6060--6969

5050--5959

EtEtàà a a rischio rischio

(aa)(aa)

Prospective Studies Collaboration, Lancet 2002; 360: 1903Prospective Studies Collaboration, Lancet 2002; 360: 1903--1313708 Mo708 Mo

2232 Mo2232 Mo

Hypertension Prevalence vs Stroke Mortality in 6 European Hypertension Prevalence vs Stroke Mortality in 6 European and 2 North American Countries, Men and Women Combinedand 2 North American Countries, Men and Women Combined

10 20 30 40 50 60 70Hypertension prevalence (%)

10

20

30

40

50

60Mortality per 100 000 inhabitants

FinlandFinland

GermanyGermany

SpainSpain

EnglandEnglandItalyItaly

SwedenSwedenUnited StatesUnited States

CanadaCanada

WolfWolf--Maier et al., JAMA 2003; 289: 2303Maier et al., JAMA 2003; 289: 2303--23692369

1500 Mo1500 Mo

Cumulative Incidence of ESRD according to Cumulative Incidence of ESRD according to the 6 Blood Pressure Categoriesthe 6 Blood Pressure Categories

Tozawa M et al., Hypertension 2003; 41: 1341Tozawa M et al., Hypertension 2003; 41: 1341--13451345

NormalNormal

2.02.0

1.51.5

1.01.0

0.50.5

0.00.0

2.02.0

1.51.5

1.01.0

0.50.5

0.00.000 44 88 1212 1616

FollowFollow--up time since screening (years)up time since screening (years)

00 44 88 1212 1616

Cum

ulat

ive

inci

denc

e of

ESR

D (%

)C

umul

ativ

e in

cide

nce

of E

SRD

(%)

Severe HTSevere HT

Moderate HTModerate HT

Mild HTMild HT

HighHigh--normalnormal

NormalNormal

OptimalOptimal

Severe HTSevere HT

Moderate HTModerate HT

Mild HTMild HT

HighHigh--normalnormal

OptimalOptimal

MenMen(n = 46881)(n = 46881)

WomenWomen(n = 51878)(n = 51878)

0

10

20

30

40

50

60

1694 Mo1694 Mo Anakevar MS et al., NEJM 2004; 351: 1285Anakevar MS et al., NEJM 2004; 351: 1285--12951295

Estimates of the Rates of Death at Three Years from Estimates of the Rates of Death at Three Years from Cardiovascular CausesCardiovascular Causes

Est

imat

ed e

vent

rat

e (%

)E

stim

ated

eve

nt r

ate

(%)

Death fromDeath fromCV causesCV causes

ReinfarctionReinfarction CHFCHF StrokeStroke ResusResus--citationcitation

CompositeCompositeend pointend point

GFR (ml/min)GFR (ml/min)≥≥ 75.075.060.060.0--74.974.945.045.0--59.959.9< 45.0< 45.0

P < 0.001P < 0.001

2230 Mo2230 Mo

Hypertension Control for Mean and Women,Hypertension Control for Mean and Women,by Age Group and Country: 140/90 mmHgby Age Group and Country: 140/90 mmHg

Hypertension 2004; 43: 10Hypertension 2004; 43: 10--1717

MenMenMen WomenWomenWomen

0

10

20

30

40

50

60

70

80

90

100

35 - <45 45 - <55 55 - <65 65 - <75

USASpainEnglandGermanyItalyCanadaSweden

Hyp

erte

nsio

n co

ntro

l (%

)H

yper

tens

ion

cont

rol (

%)

Age (years)Age (years)

0

10

20

30

40

50

60

70

80

90

100

35 - <45 45 - <55 55 - <65 65 - <75

USASpainEnglandGermanyItalyCanadaSweden

Age (years)Age (years)

Volpe, J Hypertens 2007

Distribuzione dei valori di pressione arteriosa in 9 studi condotti in Italia su

40.829 ipertesi trattati

Ottimale(<120/80 mmHg)

Normale(120-129/80-84

mmHg)

Normale-alta(130-139/80-85

mmHg)

40

35

30

25

20

15

10

5

0Grado 1

(140-159/90-99 mmHg)

Grado 2 o 3(>160/>100

mmHg)

ISH(>140/<90

mmHg)

4,5

9,2 8,3

39,0

32,6

5,1

Per

cen

tual

e di

paz

ien

ti (

%)

n=1831 n=3739 n=3374 n=15.904 n=13.297 n=2081

Volpe, J Hypertens 2007

Prevalenza dei fattori di rischio cardiovascolare in 15 studi condotti in Italia su 52.715 ipertesi

trattati e non trattati

Fumo Ipercolesterolemia Sovrappeso o obesità

60

50

40

30

20

10

0Diabete mellito

28,7

55,9

36,4

15,0

Per

cen

tual

e di

paz

ien

ti (

%)

n=15.144 n=29.473 n=19.162 n=7903

2220 Mo2220 Mo

Global Cardiovascular Risk Stratification according to ESH/ESCGlobal Cardiovascular Risk Stratification according to ESH/ESC

Volpe M et al., J Hypertens 2007; 25: 1491Volpe M et al., J Hypertens 2007; 25: 1491--14981498

Moderate riskModerate risk(n = 12819)(n = 12819)

Low riskLow risk(n = 8782)(n = 8782)

Very high riskVery high risk(n = 4787)(n = 4787)

High riskHigh risk(n = 11416)(n = 11416)

33.9%

30.2%12.7%12.7%

23.2%

Probability of Survival in HT vs ControlProbability of Survival in HT vs ControlProbability of Survival in HT vs Control

6138 M6138 M

MalesMalesMales

FemalesFemalesFemales

Probability of Probability of survivalsurvival

ReductionReduction(years)(years)

Probability of Probability of survivalsurvival

ReductionReduction(years)(years)

Probability of Probability of survivalsurvival

ReductionReduction(years)(years)

35 years35 years35 years 45 years45 years45 years 55 years55 years55 years

41.5

37.5

32.5

25

43.5

40.5

36.5

31.5

32

29

26

20.5

37

35

32

28.5

23.5

22.5

19.5

17.5

27.5

27

24.5

23.5

11

44

66

0.50.5

33

44

11

66

11.511.5

22

55

8.58.5

44

99

16.516.5

33

77

1212

Normal BPNormal BP

130/90130/90

140/95140/95

150/100150/100

Normal BPNormal BP

130/90130/90

140/95140/95

150/100150/100

779 Mo779 Mo

Effect of AntEffect of Ant--HT Treatment on Risk Reduction HT Treatment on Risk Reduction of CV Diseasesof CV Diseases

Data from 17 studies, 48.000 ptsData from 17 studies, 48.000 pts

-60

-50

-40

-30

-20

-10

0

-60

-50

-40

-30

-20

-10

0Risk ReductionRisk Reduction

(%)(%)

HeartHeartfailurefailure

Fatal/nonfatalFatal/nonfatalstrokesstrokes

CVDCVDdeathsdeaths

Fatal/nonfatalFatal/nonfatalCHD eventsCHD events

-52--5252

-38--3838

-21--2121-16--1616

6398 M6398 M

1.501.50

1.251.25

1.001.00

0.750.75

0.500.50

0.250.25

1.501.50

1.251.25

1.001.00

0.750.75

0.500.50

0.250.25

1.501.50

1.251.25

1.001.00

0.750.75

0.500.50

0.250.25

1.501.50

1.251.25

1.001.00

0.750.75

0.500.50

0.250.25

1.501.50

1.251.25

1.001.00

0.750.75

0.500.50

0.250.25

1.501.50

1.251.25

1.001.00

0.750.75

0.500.50

0.250.25

SBP difference between randomized groups (mmHg)SBP difference between randomized groups (mmHg)

Relative risk of outcome eventRelative risk of outcome event

StrokeStroke Major CVDMajor CVD CHDCHD

CVD deathCVD death

Heart failureHeart failure Total mortalityTotal mortality

-10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4

-10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4

-10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4

-10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4 -10 -8 -6 -4 -2 0 2 4

BP Lowering Coll TrialistsBP Lowering Coll Trialists’’ Group 2003Group 2003

754 Mo754 Mo

Estimated Effect of a 12 mmHg Reduction in SBP over 10 Years Estimated Effect of a 12 mmHg Reduction in SBP over 10 Years on the Numberon the Number--NeededNeeded--toto--Treat to Prevent a Cardiovascular DeathTreat to Prevent a Cardiovascular Death

Ogden LG et al., Hypertension 2000; 35: 539Ogden LG et al., Hypertension 2000; 35: 539

SBP/DBP (mmHg)SBP/DBP (mmHg)

130130--139 / 85139 / 85--8989

140140--159 / 90159 / 90--9999

>> 160 / 160 / >> 100100

Risk Group ARisk Group A

486486

273273

3434

Risk Group BRisk Group B

3636

2727

1212

Risk Group CRisk Group C

2121

1818

1111

753 Mo753 Mo

Estimated Effect of a 12 mmHg Reduction in SBP over 10 Years Estimated Effect of a 12 mmHg Reduction in SBP over 10 Years on the Numberon the Number--NeededNeeded--toto--Treat to Prevent a Cardiovascular EventTreat to Prevent a Cardiovascular Event

Ogden LG et al., Hypertension 2000; 35: 539Ogden LG et al., Hypertension 2000; 35: 539

SBP/DBP (mmHg)SBP/DBP (mmHg)

130130--139 / 85139 / 85--8989

140140--159 / 90159 / 90--9999

>> 160 / 160 / >> 100100

Risk Group ARisk Group A

2525

2020

1010

Risk Group BRisk Group B

1313

1111

77

Risk Group CRisk Group C

1010

99

88

2221 Mo2221 Mo

Relative Frequencies of Patient Adherence to AHTRelative Frequencies of Patient Adherence to AHTat Baseline and during Followat Baseline and during Follow--upup

Mazzaglia G et al., Circulation 2009; 120: 1598Mazzaglia G et al., Circulation 2009; 120: 1598--16051605

1 2 3 4 5 6 7 8 9 10 11 12 0

20

40

60

80

100

High (n = 1516) Intermediate (n = 7624) Low (n = 9666)

Rel

ativ

e fr

eque

ncie

s (%

)R

elat

ive

freq

uenc

ies (

%)

Time units (6 months)Time units (6 months)

2222 Mo2222 Mo

Relationship between the Adherence to AHT and CV EventsRelationship between the Adherence to AHT and CV Events

Mazzaglia G et al., Circulation 2009; 120: 1598Mazzaglia G et al., Circulation 2009; 120: 1598--16051605

AdherenceAdherence

Low (< 40%)Low (< 40%)

Intermediate (40% to 79%)Intermediate (40% to 79%)

High (High (≥≥ 80%)80%)

HRHR

1.001.00

0.860.86

0.620.62

PP

0.1090.109

0.0320.032

2258 Mo2258 Mo

I I NumeriNumeri delldell’’IpertensioneIpertensione ArteriosaArteriosa a a LivelloLivelloPlanetarioPlanetario

7.6 7.6 milionimilioni didi mortimorti premature / anno (13.6% del premature / anno (13.6% del totaletotale))

92 92 milionimilioni didi annianni didi disabilitdisabilitàà (6.0% del (6.0% del totaletotale))

54% 54% deglidegli ictus, 47% ictus, 47% delledelle cardiopatiacardiopatia ischemicheischemiche

80% 80% didi questiquesti eventieventi neinei paesipaesi non non industrializzatiindustrializzati

70 70 miliardimiliardi didi dollaridollari allall’’annoanno per per ll’’insufficienteinsufficiente controllocontrollo della della pressionepressione (10% della (10% della spesaspesa mondialemondiale annuaannua per la salute)per la salute)

1000 1000 miliardimiliardi didi dollaridollari: : proiezioneproiezione deidei costicosti direttidiretti neinei prossimiprossimidiecidieci annianni

3600 3600 miliardimiliardi didi costicosti indirettiindiretti / anno/ anno