Casablanca, le 30 Avril 2011 MEDITERANEAN GROUP FOR STUDY DIABETES

Prospective Studies Collaboration, Lancet 2002 StrokeIHD IHD and Stroke related death regarding to age and systolic blood pressure level a metaanalysis

BLOOD PRESSURE GOAL FOR DIABETIC PATIENTS Guidelines YearBP Goal JNC72003<130 / 80mmHg WHO / ISH2003<130 / 80mmHg BHS2004<130 / 80mmHg HAS2005<130 / 80mmHg ESH2007<130 / 80mmHg AHA2007<130 / 80mmHg ADA2008<130 / 80mmHg Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA. 2003;289:2560–2572. World Health Organization, International Society of Hypertension Writing Group World Health Organization (WHO⁄ International Society of Hypertension (ISH) statement on management of hypertension. J Hypertens. 2003;21:1983–1992. Williams B, Poulter NR, Brown MJ, et al. British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. BMJ. 2004;328:634–640. Mancia G, De Backer G, Dominiczak A, et al Guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2007;25:1105–1187. Rosendorff C, Black HR, Cannon CP, et al. Treatment of hypertension in the prevention and management of ischemic heart disease. A scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation. 2007;115:2761–2788. American Diabetes Association. Standards of medical care in diabetes – Diabetes Care. 2008;31(suppl 1):S12–S54. C Level of evidence

Zanchetti et al. Journal of Hypertension 2009, Achieved systolic blood pressure (SBP) in diabetic patients included in trials comparing placebo (or less intense) with more intense antihypertensive treatment (ordinates at left), and reductions in major cardiovascular (CV) events (ordinates at right).

ABCD RW Schrier et al. Kidney Int 2002;61: ) 137±0.7/81±0.3 mm Hg 128±0.8/75±0.3 mm Hg

CV outcomes according to intervention: Intensive vs moderate ABCD RW Schrier et al. Kidney Int 2002;61:

INVEST Cooper-DeHoff RM et al. JAMA 2010;304:61-8 >140mmHg <130mmHg mmHg

INVEST Cooper-DeHoff RM et al. JAMA 2010;304:61-8

N Engl J Med 2010;362: N Engl J Med 362;17 nejm.org april 29, 2010 Average : Standard vs Intensive, Delta = 14.2 Mean # Meds Intensive: Standard:

CharacteristicMean or % Blood Pressure mmHg139/76 On Antihypertensive %87 Creatinine (mg/dL)0.9 eGFR (mL/min/1.73m 2 )92 DM Duration (yrs) * 10 A1C (%)8.3 BMI (kg/m 2 )32 * Median value CharacteristicMean or % Age (yrs)62 Women %48 2° prevention %34 Race / Ethnicity White %61 Black %24 Hispanic %7 Stable Type 2 Diabetes >3 months HbA1c 7.5% to 11% (or <9% if on more meds) High CVD risk = clinical or subclinical disease or >2 risk factors Age (limited to <80 years after Vanguard) ≥ 40 yrs with history of clinical CVD (secondary prevention) ≥ 55 yrs otherwise Urine protein <1.0 gm/24 hours or equivalent Serum Creatinine <1.5 mg/dl ACCORD BP S t u d y Les patients inclus sont âgés et souvent non proteinuriques

Dogma Disputed: Can Aggressively Lowering Blood Pressure in Hypertensive Patients with Coronary Artery Disease Be Dangerous? F Messerli et al. Ann Intern Med. 2006;144: INVEST Secondary analysis of data from

F Messerli et al. Ann Intern Med. 2006;144: INVEST

CORONARY BLOOD FLOW ON DIASTOLE

Bakris GL et al. Am J Kidney Dis 2000; 36(3): r = 0.69;P < 0.05 PAM 1 (mmHg) 130/85 1 Préssion artérielle moyenne 2 Débit de filtration glomérulaire 140/90 HTA non traitée Modification du DFG 2 (ml/min/an) META ANALYSE DES CORRLATION ENTRE FONCTION RENALE & PRESSION ARTERIELLE

Independent and Additive Impact of BP Control and ARB on Renal Outcomes in the Irbesartan Diabetic Nephropathy Trial: Clinical Implications and Limitations M A Pohl et al. J Am Soc Nephrol trial IDNT

Adler et al., Kidney Int, (%) 10 5 ESRD * Estimate from the °UKPDS and the *RENAAL studies Mortality ° Renal failure in type 2 diabetes “a medical catastrophe of world-wide dimension” Ritz, AJKD (1999) 34: 795 Renal failure in type 2 diabetes “a medical catastrophe of world-wide dimension” Ritz, AJKD (1999) 34: 795 ANNUAL ESRD AND MORTALITY IN TYPE 2 DIABETICS WITH OVERT NEPHROPATHY

A Zanchetti, Guido Grassi, G Mancia: Wisdom should not be taken for evidence When should antihypertensive drug treatment be initiated and to what levels should systolic blood pressure be lowered? A critical reappraisal Journal of Hypertension 2009, 27:923–934

BP GOAL IN HYPERTENSIVE TREATYED PATIENT: The lower, NOT the better Reappraisal ESH 2009 BP GOAL IN HYPERTENSIVE TREATYED PATIENT: The lower, NOT the better Reappraisal ESH 2009 G Mancia et al ESH 2007 & Reappraisal 2009Journal of hyprttrsion CV Mortality BP Reappraisal ESH 2009 ESH 2007 Curve The

Central SBP: difference 4,3 mm Hg (p < 0,0001) Peripheral SBP: difference 0,7 mm Hg (p < 0,2) 2073 patients amlodipine + Perindopril atenolol + thiazide

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