Actualizaciones en HTA ENERO-FEBRERO 2023

Novedades en hipertensión arterial y riesgo vascular: Enero-Febrero 2023:
Los días 23-26 de Junio 2023 tendrá lugar en Milán el 32nd European Meeting on Hypertension and Cardiovascular Protection, organizado por la European Society of Hypertension.
ABSTRACT SUBMISSION CLOSING: January 8, 2023
INSTRUCTIONS FOR ABSTRACT SUBMISSION
Abstracts can be submitted via the online Abstract Submission Service only. Abstracts sent by fax or email will not be accepted
Abstract must be in English
The deadline for abstract submission is midnight Central European Time on January 8, 2023. Abstracts submitted after this date will not be accepted
The complete abstract must not exceed 180 characters for the TITLE and 340 words / 2800 characters for the BODY
Type the text, including tables and figures, in single-line spacing and using Times New Roman 11. Do not use smaller type.
TITLE: capitalize the entire title. Spell out words. Do not use abbreviations and check that your title is complete in case you copy and paste it into the field
AUTHORS/AFFILIATIONS: you may enter up to 20 authors in the authors list and 10 affiliations. The presenting must be part of the authors list included in the submitted abstract. The names of authors will be published as listed on the submission form. Please make sure you have enter the full list of authors. The authors’ order and details (names, cities, country codes) will be published as entered in the form
TEXT: begin the text on a new line. The text should be arranged using the following headings: objective, design and method, results and conclusions
Do not include authors, institutions, city and abbreviations in the title or in the text since the grading and selection process is blinded
Do not include grant acknowledgements in the abstract content. Do not cite keywords or references in the abstract, as they are not allowed and will be deleted
Abstract will be accepted according to scientific merit
ESH 2023 allows the submission of abstracts for original contribution to the field only.
For any further information, please contact:  esh2023.abs@aimgroup.eu
Últimas publicaciones relevantes en el campo de la HTA:
La primera publicación, son los resultados del ensayo clínico TIME, publicado en Lancet, y que esperamos que ponga punto final a la polémica sobre cuál es el mejor horario para la administración del tratamiento antihipertensivo, y la segunda otro ensayo clínico, en población mayor de 65 años, en el que se comparan el tratamiento con clortalidona versus hidroclorotiazida y su efecto sobre eventos cardiovasculares, publicado en New England Journal of Medicine.
Mackenzie IS, Rogers A, Poulter NR, Williams B, Brown MJ, Webb DJ et al., on behalf of the TIME Study Group. Cardiovascular outcomes in adults with hypertension with evening versus morning dosing of usual antihypertensives in the UK (TIME study): a prospective, randomised, open-label, blinded-endpoint clinical trial. Lancet 2022;400:1417-1425
SUMMARY
Background: Studies have suggested that evening dosing with antihypertensive therapy might have better outcomes than morning dosing. The Treatment in Morning versus Evening (TIME) study aimed to investigate whether evening dosing of usual antihypertensive medication improves major cardiovascular outcomes compared with morning dosing in patients with hypertension.
Methods: The TIME study is a prospective, pragmatic, decentralised, parallel-group study in the UK, that recruited adults (aged ≥18 years) with hypertension and taking at least one antihypertensive medication. Eligible participants were randomly assigned (1:1), without restriction, stratification, or minimisation, to take all of their usual antihypertensive medications in either the morning (0600–1000 h) or in the evening (2000–0000 h). Participants were followed up for the composite primary endpoint of vascular death or hospitalisation for non-fatal myocardial infarction or non-fatal stroke. Endpoints were identified by participant report or record linkage to National Health Service datasets and were adjudicated by a committee masked to treatment allocation. The primary endpoint was assessed as the time to first occurrence of an event in the intention-to-treat population (ie, all participants randomly assigned to a treatment group). Safety was assessed in all participants who submitted at least one follow-up questionnaire. The study is registered with EudraCT (2011-001968-21) and ISRCTN (18157641), and is now complete.
Findings: Between Dec 17, 2011, and June 5, 2018, 24 610 individuals were screened and 21 104 were randomly assigned to evening (n=10 503) or morning (n=10 601) dosing groups. Mean age at study entry was 65·1 years (SD 9·3); 12 136 (57·5%) participants were men; 8968 (42·5%) were women; 19 101 (90·5%) were White; 98 (0·5%) were Black, African, Caribbean, or Black British (ethnicity was not reported by 1637 [7·8%] participants); and 2725 (13·0%) had a previous cardiovascular disease. By the end of study follow-up (March 31, 2021), median follow-up was 5·2 years (IQR 4·9–5·7), and 529 (5·0%) of 10 503 participants assigned to evening treatment and 318 (3·0%) of 10 601 assigned to morning treatment had withdrawn from all follow-up. A primary endpoint event occurred in 362 (3·4%) participants assigned to evening treatment (0·69 events [95% CI 0·62–0·76] per 100 patient-years) and 390 (3·7%) assigned to morning treatment (0·72 events [95% CI 0·65–0·79] per 100 patient-years; unadjusted hazard ratio 0·95 [95% CI 0·83–1·10]; p=0·53). No safety concerns were identified.
Interpretation: Evening dosing of usual antihypertensive medication was not different from morning dosing in terms of major cardiovascular outcomes. Patients can be advised that they can take their regular antihypertensive medications at a convenient time that minimises any undesirable effects.
Funding British Heart Foundation.
TIME Study: se trata de un estudio pragmático, prospectivo, con asignación aleatoria, abierto, con evaluación a ciegas de los resultados clínicos finales. Ha sido llevado a cabo en Reino Unido. Se incluyeron 21.104 adultos ≥ 18 años, con una edad media de 65,1 años (DE 9,3), 57,5% varones.  Se realizó una asignación aleatoria a dos grupos; uno con administración de la medicación antihipertensiva por la mañana (06:00-10:00) y otro por la noche (20:00-00:00).  Tras un seguimiento medio de 5,2 años (IQR 4,9-5,7) no se observaron diferencias entre los 2 grupos en el objetivo compuesto primario: HR 0,95 (IC 95% 0,83-1,10) a diferencia de los resultados observados en los estudios MAPEC e HYGIA, realizados en nuestro país por el mismo grupo. Hay que resaltar que la adherencia fue peor en el grupo con asignación vespertina de la medicación antihipertensiva.
Ishani A, Cushman WC, Leatherman SM, Lew RA, Woods P, Glassman P et al. for the Diuretic Comparison Projectr Writing Group.  Chlortalidone vs. Hydrochlorothiazide for Hypertension–Cardiovascular Events. N Engl J Med 2022;387:2401-2410
SUMMARY
Background: Whether chlorthalidone is superior to hydrochlorothiazide for preventing major adverse cardiovascular events in patients with hypertension is unclear.
Methods: In a pragmatic trial, we randomly assigned adults 65 years of age or older who were patients in the Department of Veterans Affairs health system and had been receiving hydrochlorothiazide at a daily dose of 25 or 50 mg to continue therapy with hydrochlorothiazide or to switch to chlorthalidone at a daily dose of 12.5 or 25 mg. The primary outcome was a composite of nonfatal myocardial infarction, stroke, heart failure resulting in hospitalization, urgent coronary revascularization for unstable angina, and non–cancer-related death. Safety was also assessed.
Results: A total of 13,523 patients underwent randomization. The mean age was 72 years. At baseline, hydrochlorothiazide at a dose of 25 mg per day had been prescribed in 12,781 patients (94.5%). The mean baseline systolic blood pressure in each group was 139 mm Hg. At a median follow-up of 2.4 years, there was little difference in the occurrence of primary-outcome events between the chlorthalidone group (702 patients [10.4%]) and the hydrochlorothiazide group (675 patients [10.0%]) (hazard ratio, 1.04; 95% confidence interval, 0.94 to 1.16; P = 0.45). There were no between-group differences in the occurrence of any of the components of the primary outcome. The incidence of hypokalemia was higher in the chlorthalidone group than in the hydrochlorothiazide group (6.0% vs. 4.4%, P<0.001).
Conclusions: In this large pragmatic trial of thiazide diuretics at doses commonly used in clinical practice, patients who received chlorthalidone did not have a lower occurrence of major cardiovascular outcome events or non–cancer-related deaths than patients who received  ydrochlorothiazide. (Funded by the Veterans Affairs Cooperative Studies Program; ClinicalTrilas.gov number, NCT02185417).
Comentario: El uso de la clortalidona para el tratamiento de la HTA fue aprobado por la FDA en 1960. No obstante, su uso fue desplazado en la práctica clínica por la hidroclorotiazida, aprobado por la FDA en 1977.  Este último fármaco es el más frecuentemente asociado a inhibidores del sistema Renina Angiotensina en asociaciones fijas, las cuales son recomendadas como opción de primera línea en muchos hipertensos.  No obstante, cabe recordar que la dosis que figura con frecuencia en estas combinaciones (12,5 mg) es muchas veces insuficiente para el control de la HTA, y que la más recomendada sería la de 25 mg. En este ensayo clínico, llevado a cabo en 13.523 sujetos con una edad media de 72,5 años, que recibían 25 o 50 mg al día de hidroclorotiazida, fueron asignados de forma aleatoria a seguir con su tratamiento inicial (hidroclorotiazida 25 o 50 mg) o a cambiar a clortalidona (12,5-25 mg).  No se modificó el resto de tratamiento antihipertensivo: el porcentaje de tratamiento combinado fue similar entre ambos grupos, con una media de antihipertensivos de 2,6±1,0 en el grupo asignado a clortalidona, y de 2,6±1,1  en el grupo asignado a hidroclorotiazida.
Tras un seguimiento medio de 2,4 años, no se observaron diferencias en el objetivo primario entre ambos grupos (Objetivo primario: compuesto de infarto de miocardio no fatal, ictus, hospitalización por insuficiencia cardiaca, revascularización coronaria urgente por angina inestable, y mortalidad no relacionada con cáncer). Sí cabe destacar que la hipokaliemia fue más frecuente en el grupo tratado con clortalidona respecto al tratado con hidroclorotiazida (6,0% vs 4,4%, respectivamente; p <0.001.
En mi opinión, la conclusión en la práctica clínica de este ensayo este ensayo clínico es que no hay motivos para cambiar el uso de hidroclorotiazida a la dosis plenas recomendadas de 25 mg al día, por clortalidona, excepto en el subgrupo de pacientes con HTA resistente, que probablemente se beneficiaría más del uso de la clortalidona 25 mg/dia.