Introduction

1. Introduction Michel Burnier Centre Hospital University Vaudois Lausanne, Switzerland Relevant disclosure of interest: Consultant to Daiichi Sankyo and the Menarini group

2. Housekeeping • Please TURN OFF all mobile electronic devices • Fire exits • Discussion

3. Faculty • Professor Massimo Volpe, Co-chair • University of Rome “La Sapienza”, Rome, Italy • Professor Michel Burnier, Co-chair • Centre Hospital University Vaudois, Lausanne, Switzerland • Professor Vivencio Barrios • University Hospital Ramón y Cajal, Madrid, Spain • Professor Krzysztof Narkiewicz • Medical University of Gdańsk, Gdańsk, Poland • Professor Andrew Coats • Norwich Research Park, Norwich, UK

4. 18:30Chairperson’s introduction Michel Burnier 18:45Olmesartan-based therapies: optimising BP goal achievement and cardiovascular risk reduction in hypertensive patients Vivencio Barrios 19:05Effectively treating hypertension in the cardiovascular setting: patient case studies from daily clinical practice Krzysztof Narkiewicz and Andrew Coats 19:25Chairperson’s discussion All 19:35Hypertension in patients at risk of cardiovascular disease: the key role of patient adherence Massimo Volpe 19:50–Discussion and summary 20:00Massimo Volpe Agenda

5. Objectives of the symposium • Highlight challenges in the clinical management of patients at increased CV risk due to hypertension • Discuss the benefits of single-pill fixed-dose combinations of antihypertensive drug therapy in patients at increased CV risk • Share real-life experiences in treating hypertension in the context of other chronic diseases • Look at how focusing on adherence could improve patient care and BP goal achievement • Think about our role as teachers/mentors in spreading the message about the need for better hypertension management to reduce the burden of CV disease

6. Attributable deaths (X 1000) 0 2000 4000 6000 8000 High Blood Pressure Smoking High cholesterol Child underweight for age Unsafe sex Low fruit and vegetable intake Overweight and obesity Physical inactivity Alcohol use Indoor air pollution (solid fuels) Globally, hypertension is a leading risk factor for premature mortality Lopez et al. Lancet 2006;367:1747–57

7. As cardiologists, we are well aware that the burden of CV disease in Europe is high • Annually, CV disease causes: >4.3 million deaths in Europe (48%) • CHD is the most frequent cause of death in Europe per se: • 1.92 million deaths/year • Stroke is second most frequent: • 1.24 million deaths/year • Overall, CV disease is estimated to cost the EU economy €192 billion a year Allender et al. European Heart Network 2008 http://www.ehnheart.org/cvd-statistics.html

8. We are happy with the BP treatment goals that we advise physicians and patients about • WHO: 2003 • <140/90 mmHg (<130/80 mmHg for diabetics, CKD or CVD)1 • JNC-7: 2003 • <140/90 mmHg (<130/80 mmHg for diabetics or CKD)2 • ESH: 2009 • <140/90 mmHg (<130/80 mmHg for CKD or CVD)3 1. Whitworth et al. J Hypertens 2003;21:1983–922. Chobanian et al. Hypertension 2003;42:1206–523. Mancia et al. J Hypertens 2009;27:2121–58

9. For cardiologists, it is well established that elevated BP has a strong correlation with CV risk 8x 8 7 6 4x 5 CV mortality risk 4 2x 3 2 1 0 115/75 135/85 155/95 175/105 SBP/DBP (mmHg) Adapted from Lewington et al. Lancet 2002;360:1903–13

10. Even high-normal BP is associated with a significant increase in CV risk* 1968 subjects without diabetes, stroke or MI, or any CV, antidiabetic or lipid-lowering medications followed for a median of 12.8 years 10 9 8 Hypertension (≥140/90 mmHg) High-normal (130–139/85–89 mmHg) Normal (120–129/80–84 mmHg) Optimal (<120/80 mmHg) 7 6 1.8x 5 Cumulative hazard ofcomposite endpoint* (%) 4 (p=0.046) 3 2 1 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 Years *Cardiovascular death, non-fatal myocardial infarction and stroke Sehestedt et al. J Hypertens 2009;27:1165–71

11. We are also well aware of how elevated BP and other factors combine to multiply CV risk Event rates* in patients with high-normal BP with/without risk factors or subclinical organ damage (SOD) 10-year event* rate (%) <3 risk factors no SOD <3 risk factors + SOD ≥3 risk factors *Cardiovascular death, non-fatal myocardial infarction and stroke SOD, subclinical organ damage Sehestedt et al. J Hypertens 2009;27:1165–71

12. All cardiovascular events 15 12 9 6 3 0 HR= 0.73, 95% CI: 0.61-0.86p=0.0002 Placebo Felodipine 0 6 12 18 24 30 36 42 48 54 60 0 6 12 18 24 30 36 42 48 54 60 Follow-up (months) What many physicians may not fully appreciate is that even small BP reductions can significantly lower CV risk 9,800 hypertensive patients, randomised to low-dose felodipine (5 mg) or placebo (baseline BP 159/92.5 mmHg) SBP response 170 160 150 140 130 120 Placebo (N=4870) Felodipine (N=4841) Proportion of patients with events (%) SBP (mmHg) Difference: 4.2/2.1 mmHg (p<0.001) Time (months) Final BP: Placebo = 141.6/83.9Felodipine = 138.1/82.3 Liu et al. J Hypertens 2005;23:2157–72

13. As specialists, we have a duty to communicate that hypertension management must improve Proportion of treated patients with BP control (%) Germany 33.6 Turkey 19.8 Canada 41.0 Japan 55.7 England 29.2 Greece 49.5 USA 53.1 China 28.8 Spain 35.0 Taiwan 18.0 Mexico 21.8 Egypt 33.5 Italy 37.5 South Africa 47.6 Adapted from Kearney et al. J Hypertens 2004;22:11–9

14. EUROASPIRE: Even in higher-risk patients, BP control rates are not improving in Europe Proportion of treated* CHD patients achieving BP and lipid goals from 1995–2007 (EUROASPIRE I, II, III) Decrease Increase *with BP-lowering and lipid-lowering medication †SBP <140 mmHg in EUROASPIRE I and BP <140/90 mmHg in EUROASPIRE II & III ‡Serum total cholesterol <4.5mmol.l-1 in EUROASPIRE I & II, and <5.0 mmol.l-1 in EUROASPIRE III EUROASPIRE I. Eur Heart J 1997;18:1569–82 EUROASPIRE II. Eur Heart J 2001;22:554–72 EUROASPIRE III. Eur J Cardiovasc Prev Rehabil 2009;16:121–37