Infarctul miocardic si accidentul vascular cerebral asociate cu terapii antihipertensive pe baza de diuretice

Hogea Andreea, grupa 82, seria XI

Dupa : Susan R Heckbert, Profesor de epidemiologie Noel S Weiss, Profesor de epidemiologie Barbara McKnight, Profesor de biostatistica Curt D Furberg, Profesor in stiinta sanatatii publice David S Siscovick, Profesor in medicina si epidemiologie Rozenn N Lemaitre, Profesor in medicina Kenneth M Rice, Asistent Universitar

Introducere
Hipertensiunea arteriala netratat este puternic asociat cu infarctul miocardic, cu accidentul vascular cerebral si cu insuficienta cardiaca. Rezultatele cercetrilor ntreprinse de Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) sugereaz c o doz mai mic de diuretice este mai eficient n comparaie cu blocantele canalelor de calciu si IECA, ca prim linie de tratament pentru prevenirea uneia sau mai multor forme de boli cardiovasculare n cazul pacienilor cu risc crescut i hipertensiune.

Obiectivele

acestui studiu analitic de tip caz-martor este de a analiza asociatia dintre infarctul miocardic i accidentul vascular-cerebral cu o parte din cele mai utilizate terapii antihipertensive: diuretice si -blocante, diuretice si inhibitori ai enzimei de conversie, si diuretice si blocante ale canalelor de calciu.

Materiale si metode
Modalitate de lucru: studiu caz-control pe esantioane de populatie. Participanii au fost selectai dintre pacienii care fac parte din Grupul de Sntate (Health Cooperative Group), o organizaie ampl pentru meninerea strii de sntate a populaiei localizata in Washington. Participantii : cazuri-> un numar de 353 de persoane vrsta cuprinsa intre 30 si 79 de ani care au fost supusi anterior unor tratamente cu antihipertensive i care au fost diagnosticai cu infarct miocardic i accident vascular-cerebral fatal sau nefatal, ntre anii 1989-2005 martorii-> un grup de 952 de persoane constituit aleatoriu din membrii ai Grupului de Sanatate care au fost tratati cu antihipertensive si care nu au suferit infarct miocardic sau accident vascular cerebral. Au fost exclusi pacientii cu insuficienta cardiaca, boala coronariana, diabet sau insuficienta renala cronica.

Materiale si metode
Fiecrui participant i s-a atribuit o dat de indexare. Pentru cazurile cu internare n spital, data indexrii o reprezint data internrii la primul infarct miocardic sau accident vascular cerebral. Pentru persoanele care au decedat nefiind internate in spital, data indexarii o reprezint data decesului. Data indexrii pentru grupul martor este o data generata computerizat, n mod aleatoriu, n anul calendaristic n care s-a constituit esantionul.

Analiza Statistica
Participanii au fost clasificai n funcie de tratamentul n curs la data indexrii: a. diuretice plus beta blocant (639); b.diuretice plus blocante ale canalelor de calciu (273); c. diuretice plus inhibitori de enzim de conversie ai angiotensinei(403) .
Grupul de utilizatori de tratament pe baz de diuretice plus beta blocant a reprezentat grupul de referin. Au fost mprite dozele zilnice de medicamente n mic, medie, mare. Doza zilnic modal pentru fiecare medicament generic a fost plasat n categoria medie, n vreme ce dozele zilnice sub acea cantitate au fost integrate n categoria mic . Dozele care depesc cantitatea de mai sus intr n categoria mare.

Tabelul 2 compar riscul relativ de infarct miocardic i accident vascular cerebral la pacienii care au primit cele trei tratamente antihipertensive

Rezultate
Tratamentul cu diuretice si blocante ale canalelor de calciu este asociat cu un risc mai crescut de infarct miocardic (OR 1.93, 95% marj de eroare 1.34 la 2.77) spre deosebire de tratamentul cu diuretice si beta blocante dar nu i de accident vascular-cerebral (OR 1.02, 95% CI 0.63 to 1.64). Riscul de infract miocardic i accident vascular-cerebral este mai sczut n cazul celor care au folosit diuretice plus inhibitori ai enzimei de conversie sau blocanti ai receptorilor pentru angiotensina dar nu cu mult mai sczut fa de aceia care au folosit diuretice plus beta blocante (infarct miocardic: OR 0.76, 95% CI 0.52 to 1.11; accident vascular-cerebral: OR 0.71, 95% CI 0.46 to 1.10).

Tabelul 3 compar riscul relativ de infarct miocardic i accident vascular cerebral la pacienii care au primit diferite doze de tratament

care a inclus un diuretic

Rezultate
Pacienii care au primit tratament cu diuretice plus doze mici de beta blocante servesc drept grup de referin. Dintre pacienii care au primit diuretice plus blocante ale canalelor de calciu, riscul relativ de infarct miocardic a crescut proporional cu creterea dozei de blocante de canale de calciu (de la OR 1.53, 95% CI 0.82 la 2.87 n cazul celor care au primt doz mic, la OR 2.19, 95% CI 1.12 la 4.27 pentru cei care au luat doz mare). Din contr, pentru pacienii tratai cu inhibitori de enzim de conversie ai angiotensinei, riscul de infarct miocardic scade invers proporional cu doza de inhibitori de enzim de conversie ai angiotensinei. (de la OR 1.56, 95% CI 0.77 la 3.16 pentru doz mic la OR 0.61, 95% CI 0.34 la 1.10 pentru doz mare )

Concluzii
In cazul pacientilor cu hipertensiune, administrarea de diuretice n combinaie cu blocante de canale de calciu determin un risc mai mare de infarct miocardic comparativ cu administrarea de diuretice plus beta blocante sau de diuretice plus inhibitori de enzim de conversie ai angiotensinei. Aceste rezultate susin indicaiile Institutului National pt Sanatate i Excelenta Clinica care nu recomanda administrarea de diuretice n combinatie cu blocante de canale de calciu. Este necesar s se efectueze o verificare solid i de lung durat a tratamentelor la pacientii cu hipertensiune care sunt deja supusi unor tratamente cu doze mici de diuretice, pentru a oferi o baz solid pentru recomandarea de tratamente.

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Va multumesc!