la relazione tra cuore e cervello nell’anziano ipertesole relazioni (spesso pericolose…) tra...
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Giovambattista Desideri Divisione di Geriatria
Università degli Studi Dell’Aquila
La relazione tra cuore e
cervello nell’anziano iperteso
Redfors B et al. Vascular Health and Risk Management 2013:9 149–154
Stress-induced cardiomyopathy
(Takotsubo): broken heart and mind?
Cardio-regulatory sympathetic pathways
Mazzeo AT et a. British Journal of Anaesthesia 112 (5): 803–15 (2014)
Brain–heart crosstalk: the many faces of stress-related
cardiomyopathy syndromes
Mazzeo AT et a. British Journal of Anaesthesia 112 (5): 803–15 (2014)
563,704 adult patients with stroke presenting to the ED in the US
Strata of systolic blood pressure according to
stroke and stroke subtype
Qureshi AJ et al. Am J Emerg Med. 2007; 25(1): 32–38
Changes in Systolic and Diastolic Blood
Pressure after stroke: CHHIPS study.
Potter JF et al. Lancet Neurol 2009; 8: 48–56
Risk of Myocardial Infarction or Vascular Death After First
Ischemic Stroke stratified by age and history of CAD:
The Northern Manhattan Study,
Dhamoon MS et al. Stroke. 2007;38:1752-1758
Gan et al. BMC Psychiatry (2014) 14:371
Depression and the risk of coronary heart disease:
a meta-analysis of prospective cohort studie
Atrial fibrillation is a leading cause of embolic stroke
Kannel WB et al. Am J Cardiol 1998
0
5
10
15
20
25
50-59 60-69 70-79 80-89
AF, even in the absence of cardiac valvular disease, is associated
with a 4- to 5-fold increased risk of ischemic stroke
Percentage of strokes
attributable to AF
Increased risk of cognitive and functional decline
in patients with atrial fibrillation: results of the
ONTARGET and TRANSCEND studies
Marzona I et al. CMAJ 2012. DOI:10.1503
Mortalità e morbilità nel mondo e fattori di rischio cardiovascolare
Diabete
ipercolesterolemia
Fumo
Obesità
Ipertensione
*Chart is not to scale; illustrates overlapping of risk factors
La mortalità per ictus e cardiopatia ischemica aumenta con l’aumentare dei valori pressori
Mo
rta
lità
per ictu
s
(ris
ch
io a
ssolu
to e
95
% C
I)
Pressione sistolica usuale (mm Hg)
50-59 anni
60-69 anni
70-79 anni
80-89 anni
Fasce di età:
256
128
64
32
16
8
4
2
1
0
120 140 160 180
Mo
rta
lità
per c
ard
iop
ati
a isch
em
ica
(ris
ch
io a
sso
luto
e 9
5%
CI)
Pressione sistolica usuale (mm Hg)
256
128
64
32
16
8
4
2
1
0
120 140 160 180
50-59 anni
60-69 anni
70-79 anni
80-89 anni
Fasce di età:
40-49 anni
Modificato da: Prospective Studies Collaboration. Lancet 2002;360:1903-1913
SENESCENCE = DEMENTIA
Staessen JA, et al. Hypertension 2007
Staessen JA, et al. Hypertension 2007 Gorelick PH, et al. Stroke 2011, 42:2672-2713
The innatural aging of the brain
CVRFs
silent brain
infarcts
vascular dementia
b amyloid
Alzheimer’s disease
amyloid precursor protein
neural
damage
Atherosclerosis and Neurodegeneration. Unexpected Conspirators in Alzheimer’s Dementia
Iadecola C. Arterioscler Thromb Vasc Biol 2003
brain hypoperfusion
Endothelial
dysfunction/activation
Vascular dysfunction
Secretase activity
Anatomical and perfusion images from a patient with HT and DM and an age-matched healthy control
Novak, V. & Hajjar, I. Nat. Rev. Cardiol. 7, 686–698 (2010);
Value of low dose combination treatment with blood
pressure lowering drugs: analysis of 354 randomised trials
Law MR et al. 2003;326:1427
Reduction of the incidence of stroke and IHD
events (%) when durg are used separately and
in combination at half standard dose
Efficacy: blood pressure lowering effects
(mmHg) of drugs when used at half standard
dose separately and in combination
Benefits and Harms of Intensive BP Treatment in Adults Aged 60 Years or Older: A Systematic Review and Meta-analysis
Weiss J et al. Ann Intern Med. 2017;166:419-429.
Benefits and Harms of Intensive BP Treatment in Adults Aged 60 Years or Older: A Systematic Review and Meta-analysis
Weiss J et al. Ann Intern Med. 2017;166:419-429.
Antihypertensive treatment strategies in the elderly
2013 ESH-ESC Guidelines, J Hypertens 2013
Recommendations Class Level
In elderly hypertensives with SBP ≥160 mmHg there is solid evidence to recommend reducing SBP to
between 150 and 140 mmHg.
I A
In fit elderly patients <80 years old antihypertensive
treatment may be considered at SBP values ≥140
mmHg with a target SBP <140 mmHg if treatment is well tolerated.
IIb C
In individuals older than 80 years with an initial SBP ≥160
mmHg it is recommended to reduce SBP to between
150 and 140 mmHg, provided they are in good physical and mental conditions.
I B
Antihypertensive treatment strategies in the elderly
2013 ESH-ESC Guidelines, J
Hypertens 2013
Recommendations Class Level
In frail elderly patients, it is recommended to leave
decisions on antihypertensive therapy to the treating
physician, and based on monitoring of the clinical
effects of treatment.
I C
The dark side
of………aging
Recommendations for Treatment of Hypertension in
Older Persons - AHA Guidelines
Whelton PK, et al. Hypertension 2017
Recommendations COR LOE
Treatment of hypertension with a SBP treatment goal of less
than 130 mm Hg is recommended for non institutionalized
ambulatory communitydwelling adults (≥65 years of age)
with an average SBP of 130 mm Hg or higher
I A
For older adults (≥65 years of age) with hypertension and a
high burden of comorbidity and limited life expectancy,
clinical judgment, patient preference, and a team-based
approach to assess risk/benefit is reasonable for decisions
regarding intensity of BP lowering and choice of
antihypertensive drugs.
IIa C-EO
MI and stroke: adjusted hazard ratio for achieved
SBP and DBP (reference level, 140/82 mm Hg)
Verdecchia P et al. Hypertension. 2015;65:108-114.
Vidal-Petiot et al. Lancet august 2016
CV event rates and mortality according to achieved SBP and DBP in
patients with stable CAD: an international cohort study - CLARIFY
Achieved blood pressure and cardiovascular outcomes in high-risk patients: results from ONTARGET and TRANSCEND trials
Bohm M et al. Lancet 2017
CV death, MI, Stroke,
hospitalization for HF
Does hypertension still
represent a risk factor
for stroke?
SBP differences between randomized
groups (mm Hg)
STROKE
0.25
0.50
0.75
1.00
1.25
1.50
-10 -8 -6 -4 -2 0 2 4
Rel
ati
ve
Ris
k
A B C D E F G
A = CA vs placebo;
B = ACE –I vs placebo;
C = intensive Tx vs less intensive;
D = ARB vs placebo;
E = ACE-I vs CA;
F = CA vs diuretic or β-blocker; G = ACE-I vs diuretic and β-blocker.
Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet 2003 2SPRINT NEJM 2015
1Williamson JD et al. JAMA. May 19, 2016.
-16 -14 -12
SPRINT
“elderly”2
SPRINT1
Effects of Low Blood Pressure in Cognitively Impaired Elderly
Patients Treated With Antihypertensive Drugs
Mossello E et al. JAMA Intern Med. 2015;175(4):578-585.
Normal cerebral autoregulation curve with its lower and upper
limits of MAP, and a narrowed range with a steeper curve.
Bo
od
flo
w
0 50 100 150 200 Mean blood pressure (mmHg)
Normal
Bo
od
flo
w
0 50 100 150 200 Mean blood pressure (mmHg)
Normal
Narrowed: hypertension,
hypotension, diabetes, vascular
disease, stroke, smoking
Normal cerebral autoregulation curve with its lower and upper
limits of MAP, and a narrowed range with a steeper curve.
Treatment of individual VRF including hypertension, diabetes, and hypercholesterolemia is associated with the reduced risk
of AD conversion.
Li J, et al. Neurology 2011;76:1485–1491
Vinyoles E et al. Curr Med Res Opin 2008;24:3331-3339
Toward defining the preclinical stages of Alzheimer’s disease
Modified from Mura T, et al. European Journal of Neurology 2010, 17: 252–259
CV RISK FACTORS
Circ Res 2015
Journal of Hypertension 2014, 32:1478–1487
Total mortality 0.71 0.56–0.90 0.95 0.69–1.31
CV mortality 0.69 0.50–0.97 0.94 0.61–1.47
All strokes 0.69 0.44–1.07 0.73 0.39–1.36
Heart failure 0.42 0.23–0.76 0.28 0.12–0.65
All CV events 0.65 0.50–0.86 0.69 0.48–0.99
HR CI HR CI
Subgroup starting
treatment vs. no treatment
(placebo): n: 1359
Subgroup continuing
treatment vs. no treatment
(placebo): n: 2486
J Hypertens 2014, 32:1400–1401
Le relazioni (spesso pericolose…) tra cuore e cervello
nell’anziano iperteso: i segreti di un buon rapporto di coppia
Controllare l’ipertensione fa bene
al cuore e al cervello
“The lower the better” può andare bene per
l’anziano “fit” ma non per l’anziano “frail”
“The earlier the better” aiuta
cuore e cervello rimanere “fit”
Cumulative incidence of first time acute myocardial infarction and stroke in people with and without chronic obstructive pulmonary
disease (COPD) during the follow-up period.
Feary et al, Thorax 2010;65:956
The computerised primary care records of 1 .204 .100 members of the general population aged >35 years: COPD and are at high risk of acute arteriovascular events
Myocardial infarction First time stroke
Singh B et al. JAMA Neurol. 2014 May 1; 71(5): 581–588
COPD, a potentially modifiable factor, is associated
with an increased risk of Mild Cognitive Impairment
Demenza BPCO
Diabete
Artrosi
Depressione
IRC
HF CHD
PAD
HBP
Obesità Acido Urico
Le relazioni (spesso pericolose…) tra cuore e cervello
nell’anziano iperteso: i segreti di un buon rapporto di coppia