Transcript Document

VBWG
Growth in heart disease, 2000–2050
Deaths
Population
Prevalence
35.0
30.0
25.0
Growth
by decade
(%)
20.0
15.0
10.0
5.0
0.0
2000
2010
2020
2030
2040
2050
Year
Foot DK et al. J Am Coll Cardiol. 2000;35:1067-81.
VBWG
Burden of adult hypertension
Comparison of NHANES data 1988–1994 and 1999–2000
80
Hypertensive*
P < 0.001
70
History of hypertension**
65.2
60
Hypertensive 50
adults
(millions) 40
50.0
30
20
10
0
42.3
7.7
59.2
6.0
1988–1994
1999–2000
*US adults with SBP ≥140 mm Hg, DBP ≥90 mm Hg, or using
antihypertensive medication (conventional definition)
**US adults not classified by conventional definition but told
at least twice by a healthcare professional that they had high BP
Fields LE et al. Hypertension. 2004;44:398-404.
CAMELOT: Optimal BP control
in CAD patients
VBWG
Study design:
Randomized, double-blind, multicenter,
24-month trial in patients with angiographically
documented CAD (N = 1991)
Treatment:
Amlodipine (10 mg), enalapril (20 mg),
or placebo added to background therapy
with -blockers and/or diuretics
Primary
outcome:
Incidence of CV events for amlodipine
vs placebo
IVUS substudy:
Measurement of atherosclerosis progression
using IVUS (n = 274)
Outcome:
Change in percent atheroma volume
Nissen SE et al. JAMA. 2004;292:2217-26.
CAMELOT: Baseline characteristics and
concomitant medications
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Placebo
(n = 655)
Amlodipine
(n = 663)
Enalapril
(n = 673)
P
Age, mean (y)
57.2
57.3
58.5
0.02
Men (%)
73.0
76.3
71.9
0.16
White race (%)
89.0
89.4
89.3
0.97
Body mass index, mean (kg/m2)
29.7
29.9
29.7
0.72
LDL-C, mean (mg/dL)
100
104
101
0.04
Systolic
128.9
129.5
128.9
0.76
Diastolic
77.6
77.7
77.2
0.54
Statin (%)
84.3
83.1
81.7
0.46
Diuretic (%)
33.4
32.1
26.8
0.02
-Blocker (%)
78.8
74.2
74.7
0.11
Aspirin (%)
95.4
94.4
94.7
0.69
Blood pressure, mean (mm Hg)
Concomitant medications
Nissen SE et al. JAMA. 2004;292:2217-26.
CAMELOT: Similar BP reductions from
baseline with amlodipine and enalapril
Placebo
Amlodipine
Enalapril
Systolic BP
132
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Diastolic BP
80
130
78
128
P < 0.001
mm Hg 126
P < 0.001
76
124
122
74
120
118
72
0
1
3
6
9
12
Months
15
18
21
24
0
1
3
6
9
12
15
18
21
24
Months
Nissen SE et al. JAMA. 2004;292:2217-26.
VBWG
CAMELOT: 31% Reduction in primary outcome
with amlodipine compared to standard care
0.25
Placebo
Amlodipine
31% Relative
risk reduction
P = 0.003
0.20
Cumulative
CV events
(proportion)
Enalapril
0.15
0.10
0.05
0
0
6
12
Months
18
24
Placebo
655
588
558
525
488
Enalapril
673
608
572
553
529
Amlodipine
663
623
599
574
535
No. at risk
Primary outcome = incidence of CV events
Nissen SE et al. JAMA. 2004;292:2217-26.
VBWG
CAMELOT: Reduction in primary outcome
with amlodipine, by subgroup
Favors
amlodipine
Favors
placebo
RRR (%)
P
33.9
4.1
0.002
0.91
Age, y
<65
≥65
22.9
49.3
0.07
0.006
Sex
Male
Female
26.8
42.8
0.03
0.03
Systolic BP
≤Mean
>Mean
32.2
29.6
0.03
0.04
All patients
30.9
0.003
Lipid-lowering therapy
With statin
Without statin
0.25
0.5
0.75
1.0
1.25
1.5
Hazard ratio (95% CI)
Box size indicates proportion of total study population
(ie, smaller boxes have fewer patients relative to other subgroups).
Nissen SE et al. JAMA. 2004;292:2217-26.
VBWG
CAMELOT: Slowed progression of atheroma
with amlodipine and enalapril
Atheroma volume measured using IVUS at baseline and 24 months (n = 274)
All patients
Baseline systolic BP > mean
P = 0.02
†
2.5
2.3
2.0
Change in
percent
atheroma
volume vs
baseline (%)
1.5
*
1.3
1.0
0.8
0.5
0.0
*P = 0.001 vs baseline
†P < 0.001 vs baseline
0.8
0.5
0.2
Placebo
(n = 95)
Enalapril Amlodipine
(n = 88) (n = 91)
Placebo Enalapril Amlodipine
(n = 49) (n = 40) (n = 47)
Nissen SE et al. JAMA. 2004;292:2217-26.
VBWG
CAMELOT: Continuous relationship between
rate of atheroma progression and change in SBP
LOWESS plot for combined amlodipine and enalapril drug-treatment groups
2.5
95% CI
2.0
Progression
1.5
Amlodipine and
enalapril groups
1.0
Change in percent
atheroma volume (%)
0.5
95% CI
0
–0.5
Regression
–1.0
–1.5
–2.0
–40
–30
–20
–10
0
10
20
Change in systolic BP (mm Hg)
LOWESS = locally weighted scatterplot smoothing
Nissen SE et al. JAMA. 2004;292:2217-26.
VBWG
INVEST: Similar BP control with CAS
and NCAS in hypertensive CAD patients
180
170
Calcium antagonist strategy (CAS)
Noncalcium antagonist strategy (NCAS)
160
Systolic BP 150
(mm Hg) 140
130
120
110
100
Diastolic BP 90
(mm Hg)
80
70
60
0
6
12
18
No. of patients
24
Months
30
36
42
48
CAS
11267
8558
8639
7758
7842
5721
3659
1458
796
NCAS
11309
8573
8694
7710
7850
5834
3679
1473
817
Pepine CJ et al. JAMA. 2003;290:2805-15.
VBWG
INVEST: Similar reduction in primary outcome
with CAS and NCAS in CAD patients
25
Noncalcium antagonist strategy (NCAS)
Calcium antagonist strategy (CAS)
20
15
P = 0.057
Cumulative
events
10
(%)
5
0
0
6
12
18
No. at risk
24
30
Months
36
42
48
54
60
CAS
11,267
10,921
10,716
10,512
10,008
6612
3738
1568
974
393
35
NCAS
11,309
10,991
10,785
10,536
10,048
6604
3706
1563
960
390
33
Primary outcome = first occurrence of death,
nonfatal MI, or nonfatal stroke
Pepine CJ et al. JAMA. 2003;290:2805-15.
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CAMELOT: Conclusions
• In CAD patients with “normal” BP, amlodipine
demonstrated a significant reduction in ischemia-related
CV events.
• IVUS substudy showed that progression of coronary
atherosclerosis may be minimized or slowed when BP
is further reduced below the so-called normal level.
• Results suggest optimal BP range for CAD patients
may be substantially lower than indicated by current
guidelines.
Nissen SE et al. JAMA. 2004;292:2217-26.