Les nouvelles recommadations de l'hypertension artérielle 2009:présenté lors d'une Etude Post Universitaire par
Faiçal JARRAYA, MDProfesseur Agrégé en Médecine, Néphrologue
European Hypertension Specialist
présentation PowerPoint sur les technique d'anesthésie en neurochirurgie.ppt
Recommadations Hypertension ArtéRielle 2009
1. Gafsa, le 3 Décembre 2009 Faiçal JARRAYA, MD Professeur Agrégé en Médecine, Néphrologue European Hypertension Specialist Service de Néphrologie, CHU Hédi Chaker,& UR Pathologie Rénale, Faculté de Médecine Sfax Unité Cibles pour le Diagnostic et la Thérapie. CBS LIA CNRS 135 « Gènes & Protéines dans les maladies multi géniques» COMMENT PRENDRE EN CHARGE L’HTA EN 2009 ? Laboratoires SAIPH Syndicat des Médecins Libéraux-Section Gafsa &
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3. Prevalence de l’Hypertension Artérielle chez les Adultes Ageés de 35 64 ans Italy Sweden England Spain Finland Germany Age- and sex-adjusted Hypertension defined as BP 140/90 mmHg or on treatment Modified from Wolf-Maier et al. JAMA 2003;289:2363 9 Prevalence of hypertension (%) US 37 Tunisia
4. HTA EN TUNISIE Enquête : Enquête Ariana 1997 H Ben Romdhane Age Homme Femme global 35-64ans 35.4 39.7 36.7 35-44ans 23.3 26.5 45-54ans 36.8 52.9 55-64ans 53.4 63.5
5. Le vécu: Monsieur Ali 65 ans présente une PA à 170/89mmHg. Je démarre alors un traitement antihypertenseur, un mois plus tard la PA est à 130/80, je suis satisfait de mon traitement Ai-je raison ?
6. Faiçal Jarraya OMS 1993 P N HTA-D 1993 JNC VI1996 OMS 1999 ANAES 2000 JNC VII 2003 ESH 2003 NICE 2006 …… ESH 2007 HAS 2005
15. Créatininémie et estimation du débit de filtration Glomérulaire (DFG: formule de Cockroft et Gault) Bandelette réactive urinaire (Protéinurie, hématurie) & quantification si positivité Kaliémie (sans garrot) Prélèvement à jeun: Glycémie, Cholestérol total, Triglycérides HDL (calcul LDL selon la formule de Friedwald) ECG de repos BILAN MINIMUM HAS 2005
16. ATTEINTE INFRACLINIQUE DES ORGANES CIBLES DIABETE FDR CV MALADIE CARDIOVASCULAIRE ET RENALE AVEREE Facteurs influençant le pronostic RCV= HTA x (FDR+AOC+MRCV) SM
17. SYNDROME METABOLIQUE 3 parmi 5 facteurs: 1- GAJ 5,6 – 6,9mmol/l 2- Obésité abdominale H : TT>102 cm F : TT>88 cm 3- PA>130/85mmHg 4- HDL-CT<1mmol/l (0,4g/l) (H) ou <1,2mmol/l (0,46g/l) (F) 5- TG >1,7mmol/l (1,5g/l) HTA METABOLIQUE
19. DIABETE WHO Report 1997. 25 30 35 40 45 20 15 10 5 n=69 n=1304 n=169 n=890 No Diabetes No prior MI Prior MI No prior MI Prior MI Diabetes 3.5 18.8 20.0 45.0 Mortality rate (%) MORTALITE PAR CARDIOPATHIE ISCHEMIQUE DES DIABETIQUES TYPE 2
20. FDR CV PAS et PAD Pression Pulsée (sujet âgé) Age (H > 55ans, F > 65ans) Tabagisme Histoire familiale CV précoce (H<55ans, F< 65ans) GAJ 5,6 – 6,9mmol/l HGPO pathologique Obésité abdominale H : TT>102 cm F : TT>88 cm Dyslipidémie: CT >5 mmol/l (1,9g/l) ou LDL-CT >3 mmol/l (1,15g/l) ou HDL-CT<1mmol/l (0,4g/l) (H) ou <1,2mmol/l (0,46g/l) (F) TG >1,7mmol/l (1,5g/l) Facteurs influençant le pronostic RCV= HTA x ( FDR +AOC+MRCV) - LDL-CT ≥ 1,60 g/l (4,1 mmol/l) ou - HDL-CT ≤ 0,40 g/l (1 mmol/l) HAS 2005
21. HVG électrique (Sokolow > 38mm) (HVG écho IMVG H≥ 125g/m², F ≥ 110g/m² Epaisseur intima-média carotidienne > 0,9 mm ou Plaque VOP carotido-fémorale> 12m/s Micro albuminurie 30-300 mg/24h ou albumine/créatinine: H > 22 et F>31 mg/g créatinine Discrète augmentation de la créatinine Clairance de la créatinine < 60ml/mn Facteurs influençant le pronostic RCV= HTA x (FDR+ AOC +MRCV)
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23. CŒUR: IDM, Angor, Revascularisation coronaire, insuffisance cardiaque CERVEAU: AVC ischémique, AVC hémorragique, AIT ARTERITE DES MI Rétinopathie sévère: hémorragie, exsudats, œdème papillaire REIN: Néphropathie diabétique, fonction rénale altérée, Protéinurie >300mg/24h Facteurs influençant le pronostic RCV= HTA x (FDR+AOC+ MRCV )
25. LES SUJETS A HAUT / TRES HAUT RCV PAS ≥180 mmHg et/ou PAD≥110mmHg PAS ≥160 mmHg avec PAD70mmHg Diabète Syndrome métabolique ≥ 3 FDR CV Maladie Cardiovasculaire ou rénale avérée RCV ▲ = HTA x (FDR+AOC+MRCV)
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27. Quoi de neuf en 2008: AntiHTA de 1 ère intension -bloquant ARA-2 IEC D. Thiazidique Inhibiteur calcique ASCOT, LIFE On Target ESH 2009
30. - Si PAS 140-160 et/ou PAD 90-100 et 1 ou 2 FDRCV hors HTA - Si PAS 160-180 et/ou PAD 100-110 et absence d’autres FDRCV et en présence de 1 à 2 FDRCV hors HTA DECISION DANS UN DELAI DE 3 MOIS MHD 3 mois => si objectif non atteint = débuter antiHTA - Si PAS 140-160 et/ou PAD 90-100 et absence d’autres FDRCV DECISION DANS UN DELAI DE 6 MOIS MHD 6 mois => si objectif non atteint = débuter antiHTA
31. Chez le patient hypertendu, le principal but est d’obtenir la réduction maximale du risque total de développer une maladie cardiovasculaire à long terme Action sur TOUS les FDR CV réversibles associés PA Cible < 140/90mmHg PA Cible < 130/80mmHg Chez le diabétique chez les patients à RCV élevé ou très élevé Chez ceux présentant une maladie cardiovasculaire ou rénale Quoi de neuf en 2008: PA Cible
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34. AntiHTA de 1 ère intension - bloquant ARA IEC D. Thiazidique Inhibiteur calcique ESH 2009
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36. Quoi de neuf en 2008: Choix de l’antiHTA selon le contexte
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39. Quoi de neuf en 2008: Choix de l’antiHTA selon le contexte
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41. Quoi de neuf en 2008: Choix de l’antiHTA selon le contexte
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45. Ind-Perind diminue les événements rénaux de 21% à 31% DIABETE De Galan B.E, et al. Poster ESH Berlin. J Hypertension 2008. Evénements rénaux totaux Progression de 1 stade d’albuminurie Microalbuminurie nouvellement diagnostiquée Macroalbuminurie nouvellement diagnostiquée Progression de l’atteinte rénale Diminution du risque avec Ind-Perind
59. Ho et al. Arch Intern Med 2006;166:1836–41 Results: multivariable risk of outcomes Non adhérence au traitement Effet sur l’évolution Non-adherence measure All-cause mortality OR (95% CI) All cause hospitalization OR (95% CI) Anti-hypertensives 1.58 (1.22–2.05) 1.44 (1.24–1.67) Oral hypoglycaemics 1.39 (1.07–1.82) 1.38 (1.21–1.58) Statins 2.07 (1.54–2.80) 1.39 (1.18–1.63) Summary measure 1.81 (1.46–2.23) 1.53 (1.38–1.81)
60. Mêmes définitions Mêmes conduites diagnostiques avec une intervention basée sur le niveau du RCV, touchant TOUS les FDR CV modifiables SM est une situation à haut RCV L’atteinte vasculaire infra clinique est comptabilisée (EIM, VOP) 5 antiHTA de 1 ère intension (IC, IEC, ARA2, DT, B) mais à ne pas considérer l’association DT + B Eviter B diabétogène chez le sujet obèse (SM) Prescrire de 1 ère intension un IEC-ARA2 chez le sujet diabétique HTA systolique isolée du sujet âgé, priorité aux IC et/ou DT Quoi de neuf en 2009: CONCLUSIONS
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66. Gain d’espérance de vie, 1970-2002 Entre 1970 et 2000, l’espérance de vie a augmenté de 6 ans, dont 3,9 par réduction de la mortalité CV… Lenfant C, N Engl J Med 2003;349:868 Data from the Centers for Disease Control and Prevention Mais la prévention primaire ne représente que le quart de ce gain
67. Pays en voie de développement Pays développés Causes infectieuses Maladies cardio-circulatoires Autres causes MALADIE CARDIOVASCULAIRE: 1 è re cause de mortalit é dans le monde & EN TUNISIE 100% 80% 60% 40% 20% 0% 1990 2020 1990 2020
In this study by Wolf-Maier et al., data from national sample surveys were analyzed to provide age- and sex-adjusted estimates of BP and prevalence of hypertension (BP ≥140/90 mmHg or treatment with antihypertensive medication) by country and region (Europe compared with North America). Data showed that the prevalence of hypertension was similar for the US and Canada (28% and 27%, respectively; data for Canada not shown on the slide), but was markedly higher in European countries (44.2% overall). Reference Wolf-Maier K, et al. Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States. JAMA 2003;289:2363–9.
CVD mortality increased in the metabolic syndrome: Kuopio Ischaemic Heart Disease Risk Factor Study In a study of slightly more than 1,000 males from Kuopio, Finland, followed up for 10 years, Lakka et al. showed a 3.5-fold increase in risk for cardiovascular disease (CVD) mortality. This increased risk is as high as or higher than the risk of type 2 diabetes for CVD in males described in many other studies such as the Framingham Study. Other studies suggest a much lower risk of the metabolic syndrome for CVD in nondiabetic subjects. References: Lakka HM, Laaksonen DE, Lakka TA, Niskanen LK, Kumpusalo E, Tuomilehto J, Salonen JT. The metabolic syndrome and total and cardiovascular disease mortality in middle-aged men. JAMA 2002;288:2709-2716. Alexander CM, Landsman PB, Teutsch SM, Haffner SM. NCEP-defined metabolic syndrome, diabetes, and prevalence of coronary heart disease among NHANES III participants age 50 years and older. Diabetes 2003;52:1210-1214.
Mortality from coronary heart disease in subjects with type 2 diabetes A significant number of patients with an acute MI have previously undiagnosed diabetes. Diabetics have a greater burden of atherogenic risk factors than non-diabetics, including hypertension, obesity, increased total-to-HDL-cholesterol ratio, hypertriglyceridemia, and elevated plasma fibrinogen. Patients with the constellation of abdominal obesity, hypertension, diabetes, and dyslipidemia are considered to have the insulin resistance syndrome (also called the metabolic syndrome). The CHD risk in diabetics varies widely with the intensity of these risk factors. The figure shows that the seven-year incidence rates of myocardial infarction in non-diabetic subjects (n =1373) with and without prior myocardial infarction at base line were 18.8 percent and 3.5 percent, respectively (P<0.001). The seven-year incidence rates of myocardial infarction in diabetic subjects (n = 1059) with and without prior myocardial infarction were 45.0 percent and 20.2 percent, respectively (P<0.001). The data suggest that diabetic patients without previous myocardial infarction have as high a risk of myocardial infarction as non-diabetic patients with previous myocardial infarction and provide a rationale for treating cardiovascular risk factors in diabetic patients as aggressively as in non-diabetic patients with prior myocardial infarction.
Mortality from coronary heart disease in subjects with type 2 diabetes A significant number of patients with an acute MI have previously undiagnosed diabetes. Diabetics have a greater burden of atherogenic risk factors than non-diabetics, including hypertension, obesity, increased total-to-HDL-cholesterol ratio, hypertriglyceridemia, and elevated plasma fibrinogen. Patients with the constellation of abdominal obesity, hypertension, diabetes, and dyslipidemia are considered to have the insulin resistance syndrome (also called the metabolic syndrome). The CHD risk in diabetics varies widely with the intensity of these risk factors. The figure shows that the seven-year incidence rates of myocardial infarction in non-diabetic subjects (n =1373) with and without prior myocardial infarction at base line were 18.8 percent and 3.5 percent, respectively (P<0.001). The seven-year incidence rates of myocardial infarction in diabetic subjects (n = 1059) with and without prior myocardial infarction were 45.0 percent and 20.2 percent, respectively (P<0.001). The data suggest that diabetic patients without previous myocardial infarction have as high a risk of myocardial infarction as non-diabetic patients with previous myocardial infarction and provide a rationale for treating cardiovascular risk factors in diabetic patients as aggressively as in non-diabetic patients with prior myocardial infarction.
Mortality from coronary heart disease in subjects with type 2 diabetes A significant number of patients with an acute MI have previously undiagnosed diabetes. Diabetics have a greater burden of atherogenic risk factors than non-diabetics, including hypertension, obesity, increased total-to-HDL-cholesterol ratio, hypertriglyceridemia, and elevated plasma fibrinogen. Patients with the constellation of abdominal obesity, hypertension, diabetes, and dyslipidemia are considered to have the insulin resistance syndrome (also called the metabolic syndrome). The CHD risk in diabetics varies widely with the intensity of these risk factors. The figure shows that the seven-year incidence rates of myocardial infarction in non-diabetic subjects (n =1373) with and without prior myocardial infarction at base line were 18.8 percent and 3.5 percent, respectively (P<0.001). The seven-year incidence rates of myocardial infarction in diabetic subjects (n = 1059) with and without prior myocardial infarction were 45.0 percent and 20.2 percent, respectively (P<0.001). The data suggest that diabetic patients without previous myocardial infarction have as high a risk of myocardial infarction as non-diabetic patients with previous myocardial infarction and provide a rationale for treating cardiovascular risk factors in diabetic patients as aggressively as in non-diabetic patients with prior myocardial infarction.