nessun titolo diapositiva...andrea ungar, md, phd, fesc syncope unit, hypertension centre geriatric...
TRANSCRIPT
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Andrea Ungar, MD, PhD, FESC
Syncope Unit, Hypertension Centre
Geriatric Cardiology and Medicine
University of Florence, Italy
L’INQUADRAMENTO DELL’IPERTENSIONE
ARTERIOSA NEL PAZIENTE ANZIANO:
TRA LINEE GUIDA E PRATICA CLINICA
Controllo pressorio e prognosi clinica: è più
importante il punto di partenza o di arrivo?
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Qualche certezza:
1. L’ipertensione arteriosa, soprattutto sistolica,
è un fattore di rischio anche nell’anziano
2. Il «giovane anziano» in buona salute, DEVE
essere trattato per l’ipertensione arteriosa
come il giovane (forse prima)
3. Essere ipertesi non controllati in età adulta
aumenta il rischio di ipertensione sistolica
isolata in età avanzata
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L’INQUADRAMENTO DELL’IPERTENSIONE ARTERIOSA NEL PAZIENTE ANZIANO:
TRA LINEE GUIDA E PRATICA CLINICA
Controllo pressorio e prognosi clinica: è più importante il punto di partenza o di arrivo?
Partenza
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Arrivo
L’INQUADRAMENTO DELL’IPERTENSIONE ARTERIOSA NEL PAZIENTE ANZIANO:
TRA LINEE GUIDA E PRATICA CLINICA
Controllo pressorio e prognosi clinica: è più importante il punto di partenza o di arrivo?
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• In elderly hypertensives less than 80 years old with
SBP ≥160 mmHg there is solid evidence to recommend
reducing SBP to between 150 and 140 mmHg.
• In the Fit elderly patients less than 80 years old SBP
values <140 mmHg may be considered, whereas in the
fragile elderly population SBP goals should be adapted
to individual tolerability.
• In individuals older than 80 years and with 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.
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“FIT”
elderly patient
??
“good physical
and mental
condition” ??
SBP between
140 and 150
mmHg
Dementia?? Stima funzione
renale
nell’anziano??
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Stima funzione
renale nell’anziano??
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(Berlin Initiative Study, BIS-1 and BIS-2)
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La valutazione del filtrato glomerulare nell’anziano alla luce
delle nuove formule.
Dalla scintigrafia renale alla pratica clinica.
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SIGG-SIIA 2014
Correlazione tra
Filtrato Glomerulare (FG)
Misurato e Stimato
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FGs COCKROFT-GAULT vs FG misu
Correlazione: r= 0,51160, p<0,001
0 20 40 60 80 100 120 140
FG misurato (ml/min/1.73 m 2)
0
20
40
60
80
100
120
CO
CK
RO
FT
-GA
ULT
(m
l/m
in/1
.73m
2)
r = 0.51
FGs MDRD vs FG mis
Correlazione: r= 0.62652, p<0.001
0 20 40 60 80 100 120 140
FG misurato (ml/min/1.73m 2)
0
20
40
60
80
100
120
140
160
MD
RD
(m
l/m
in/1
.73m
2)
r = 0.63
FGs CKD-EPI vs FG mis
Correlazione: r= 0.66605, p<0.001
0 20 40 60 80 100 120 140
FG misurato (ml/min/1.73m 2)
0
20
40
60
80
100
120
CK
D-E
PI
(ml/m
in/1
.73m
2)
r = 0.67
FGs BIS1 vs FG m
Correlazione: r=0.65227, p<0.001
0 20 40 60 80 100 120 140
FG misurato (ml/min/1.73 m 2)
0
20
40
60
80
100
120
140
BIS
1 (
ml/m
in/1
.73 m
2)
r = 0.65
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Creatininemia in 311 anziani ricoverati in ortopedia(65-102 anni, 81,9±8,1 anni)
0,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5 4,0
Creatinina (mg/dl)
0
50
100
150
200
250
Nu
me
ro p
azie
nti
Cr. media 0,89±0,40 mg/dl
Cr. < 1 mg/dl: 236/311 (76 %)
Ortogeriatria, AOU Careggi, Firenze
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CREATININA < = 1 mg/dl
Correlazione: r= 0.10398
20 40 60 80 100 120 140
FG (ml/min/1.73m 2)
0
20
40
60
80
100
120
CO
CK
RO
FT
-GA
ULT
(m
l/m
in/1
.73m
2)
Confidenza 95%
CREATININA > 1mg/dl
Correlazione: r= 0.48782
0 20 40 60 80 100 120
FG (ml/min/1.73m 2)
0
10
20
30
40
50
60
70
80
90
CO
CK
RO
FT
-GA
ULT
(m
l/m
in/1
.73m
2)
Confidenza 95%
r = 0.10 r = 0.49
Correlazione tra filtrato glomerulare misurato e stimato
in base ai valori di creatinina
Formula di Cockcroft-Gault
Creatinina
≤ 1mg/dL
Creatinina
> 1mg/dL
SIGG-SIIA 2014
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Correlazione tra filtrato glomerulare misurato e stimato
in base ai valori di creatinina
Formula MDRD
Creatinina
≤ 1mg/dL
Creatinina
> 1mg/dL
CREATININA <= 1 mg/dl
Correlazione: r= 0.14469
20 40 60 80 100 120 140
FG (ml/min/1.73 m 2)
40
60
80
100
120
140
160
MD
RD
(m
l/m
in/1
.73 m
2)
Confidenza 95%
CREATININA >1 mg/dl
Correlazione: r= 0.64554
0 20 40 60 80 100 120
FG (ml/min/1.73m 2)
0
10
20
30
40
50
60
70
80
MD
RD
(m
l/m
in/1
.73m
2)
Confidenza 95%
r = 0.14 r = 0.65
SIGG-SIIA 2014
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Creatininemia in 311 anziani ricoverati in ortopedia(65-102 anni, 81,9±8,1 anni)
0,0 0,5 1,0 1,5 2,0 2,5 3,0 3,5 4,0
Creatinina (mg/dl)
0
50
100
150
200
250
Nu
me
ro p
azie
nti
Cr. media 0,89±0,40 mg/dl
Cr. < 1 mg/dl: 236/311 (76 %)
Ortogeriatria, AOU Careggi, Firenze
FUNZIONE RENALE????
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V.B., 85 anni
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Ungar A et at, submitted
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Ungar A et at, submitted
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“FIT”
elderly patient
??
“good physical
and mental
condition” ??
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????
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Dementia ??
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MMSE, Clock test?????
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White matter hyperintensities and silent
infarcts are associated with an increased risk
of stroke, cognitive decline and dementia.
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The importance of hypertension in predicting
vascular dementia has been confirmed
…. but evidence on the effects of lowering of
BP is scanty and confusing
Little information was added by a cognition
sub-study of HYVET in hypertensive
octogenarians because of the inadequate
duration of follow-up showed very limited
benefit
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I problemi nascono
quando il paziente non è
più un adulto da
proteggere ma un paziente
anziano, magari «fragile e
con decadimento
cognitivo»
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Solo una minoranza di
pazienti con grave
decadimento cognitivo e
disturbi comportamentali
non hanno tollerato il
monitoraggio pressorio.
Anche nei pazienti che
non raggiungono il 75%
di misurazioni valide il
monitoraggio ha dato
indicazioni interessanti
per la terapia
Blood pressure monitoring, 2014
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Trials are urgently needed on preventing
cognitive dysfunction and on delaying
dementia when cognitive dysfunction has
begun
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172 pazienti (età media 79±5 years, 63%
donne), affetti da demenza nel 68% e MCI
nel 32% dei casi
Tutti i pazienti sono stati sottoposti a ABPM,
valutazione pressoria clinica e follow-up
clinico e cognitivo
JAMA Int Med, 2014
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JAMA Int Med, 2014
ABPM Office
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JAMA Int Med, 2014
ABPM
Office
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JAMA Int Med, 2014
AD
MCI
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Prospettive per
studi del gruppo
SIIA-SIGG
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Elena, a 103
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Grazie per l’attenzione
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Gruppo Italiano Sincope (GIS) - SIGG
Syncope and Dementia, a GIS Registry
SYD Registry
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Comorbosità (n=303)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Il 93% dei pazienti era affetto da
patologie cardiovascolari
SYD Registry
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Politerapia (n=303)
0%
10%
20%
30%
40%
50%
60%
Il 96% assumeva una
polifarmacoterapia
SYD Registry
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Casistica
globale
(n=207)
<85 anni
(n=111)
≥85 anni
(n=96)
p
Neuromediata 152 (73.4%) 81 (73.0%) 71 (74.0%) ns
Neuroriflessa 51 (24.6%) 31 (27.9%) 20 (20.8%) ns
Ortostatica 101 (48.8%) 50 (45.0%) 51 (53.0%) ns
Disautonomia
secondaria 27 (17.8%) 17 (21.0%) 10 (14.1%) ns
Jatrogena 50 (24.2%) 23 (28.4%) 27 (38.0%) ns
Cardiaca 28 (13.5%) 14 (12.6%) 14 (14.6%) ns
Strutturale 8 (3.9%) 3 (2.7%) 5 (5.2%) ns
Aritmica 20 (9.7%) 11 (9.9%) 9 (9.3%) ns
Indeterminata 27 (13.0%) 16 (14.4%) 11 (11.5%) ns
Tipi di sincope
48.8%
SYD Registry
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Higher levels of accordance with both the DASH and Mediterranean dietary patterns were
associated with consistently higher levels of cognitive function in elderly men and
women over an 11-y period. Whole grains and nuts and legumes were positively
associated with higher cognitive functions and may be core neuroprotective foods common to
various healthy plant-centered diets around the globe.
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Solo in 2 studi su 9
l’ipertensione
arteriosa era riportata
tra le comorbidità del
pazienti