A Lower Blood Pressure Goal in Patients Without Diabetes Lessens the Occurrence of Left Ventricular Hypertrophy

Abstract

A LOWER BLOOD PRESSURE GOAL IN PATIENTS WITHOUT DIABETES LESSENS THE OCCURRENCE OF LEFT VENTRICULAR HYPERTROPHY The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends a blood pressure (BP) goal of <140 ⁄90 mm Hg in most patients with hypertension and a goal of <130 ⁄80 mm Hg in patients with diabetes or chronic kidney disease. A recent scientific statement from the American Heart Association suggested adding patients with known coronary artery disease, carotid disease, peripheral artery disease, an abdominal aortic aneurysm, left ventricular dysfunction, or a calculated 10-year Framingham risk score of at least 10% to the group of patients with a BP goal of <130 ⁄80 mm Hg. These recommendations were made despite a lack of level I clinical trial evidence for benefit of more intensive treatment of BP in those patient populations. These recommendations are largely aimed at reducing the incidence of hard cardiovascular events such as myocardial infarction (MI), stroke, or heart failure. In patients with hypertension, left ventricular hypertrophy (LVH) is a major independent risk factor for stroke, MI, sudden cardiac death, and cardiovascular mortality. Yet, neither JNC 7 nor the American Heart Association (AHA) Scientific Statement specify a more aggressive BP goal in patients with LVH, and prevention of LVH is not emphasized in current guidelines. Whether more aggressive BP lowering would effectively reduce the incidence of LVH was recently tested in the Studio Italiano Sugli Effetti Cardiovascolari del Controllo della Pressione Arteriosa Sistolica (Cardio-Sis) trial. In this open-label, industry-supported trial conducted between February 2005 and February 2007, Italian researchers enrolled 1111 Italian hypertensive nondiabetic patients (93% of those screened). Inclusion criteria included age 55 years or older, a baseline systolic BP of 150 mm Hg, use of antihypertensive therapy for at least 12 weeks, and at least 1 additional risk factor (cigarette smoking, dyslipidemia, family history of premature cardiovascular disease, previous transient ischemic attack or stroke, or established coronary or peripheral artery disease). Patients were excluded if they had a history of diabetes, renal dysfunction, valvular heart disease, liver disease, atrial fibrillation, substance abuse, or a limited life expectancy. Eligible participants entered a run-in phase to make sure that at two visits 7 to 14 days apart their systolic BP on their present antihypertensive regimen was 150 mm Hg. They were then randomized in a 1:1 ratio to receive antihypertensive drug treatment to achieve either usual systolic BP control (<140 mm Hg) (n=553) or tight systolic BP control (130 mm Hg) (n=558). They were followed up every 4 months for 2 years. At baseline and at 1 and 2 years, patients had a 12-lead electrocardiogram (ECG) and laboratory blood tests performed. Treatment was open-label, with all classes of antihypertensive drugs available. Intensification or down-titration of treatment was permitted in order to achieve the specified BP goals. Drug classes were evenly distributed at baseline, except in the usualcontrol group where more patients were taking a diuretic and fewer were taking an angiotensin receptor blocker (ARB). The primary study outFrom the Division of General Internal Medicine ⁄ Division of Cardiology, University of Nevada School of Medicine; the Risk Reduction Center, Saint Mary’s Regional Medical Center, Reno, NV; the Primary Care Service Line, Ralph H. Johnson VA Medical Center, and the Division of General Internal, Medicine ⁄Geriatrics, Medical University of South Carolina, Charleston, SC Address for correspondence: Michael J. Bloch, MD, Risk Reduction Center, Saint Mary’s Regional Medical Center, 645 North Arlington Street, Suite 460, Reno, NV 89503 E-mail: mbloch@aol.com