How Low should the Blood Pressure be reduced in Patients with Hypertension and High Risk for Coronary Artery Disease?

Abstract

The more aggressive control of blood pressure among patients at high risk for coronary artery disease such as those with coronary artery disease, a 10-year Framingham risk score ≥10%, diabetes mellitus, chronic kidney disease, or other coronary artery risk equivalent with maintenance of the blood pressure below 130/80 mm Hg and below 120/80 mm Hg in patients with left ventricular dysfunction recommended by the American Heart Association (AHA) Task Force scientific statement in 2007 [1] was based upon expert medical opinion at that time, not on prospective, randomized, adequately controlled trial data [2]. The Pravastatin or Atorvastatin Evaluation and Infection TherapyThrombolysis in Myocardial Infarction (PROVE IT-TIMI) 22 trial enrolled 4,162 patients with an acute coronary syndrome (acute myocardial infarction with or without ST-segment elevation or highrisk unstable angina pectoris) [3].The lowest incidence of cardiovascular events occurred with a systolic blood pressure between 130 to 140 mm Hg and a diastolic blood pressure between 80 to 90 mm Hg with a nadir of 136/85 mm. An observational subgroup analysis was performed in 6,400 of the 22, 576 patients in the International Verapamil SR-Trandolapril Study (INVEST) [4]. These patients had diabetes mellitus and coronary artery disease. Patients were considered to have tight control of their blood pressure if they could maintain their systolic blood pressure below 130 mm Hg and their diastolic blood pressure below 85 mm Hg, usual control if they could maintain their systolic blood pressure between 130 to 139 mm Hg, and uncontrolled if their systolic blood pressure was 140 mm Hg or higher. During 16,893 patient-years of follow-up, the incidence of cardiovascular events was 12.6% in patients with usual control of blood pressure versus 19.8% in patients with uncontrolled hypertension, p <0.001 [4]. The incidence of cardiovascular events was 12.6% in patients with usual control of blood pressure versus 12.7% in patients with tight control of blood pressure (p not significant). The all-cause mortality rate was 11.0% with tight control of blood pressure versus 10.2% with usual control of blood pressure (p = 0.06). When extended follow-up was included, the all-cause mortality rate was 22.8% with tight control of blood pressure versus 21.8% with usual control of blood pressure, p = 0.04.