Coronary Artery Disease In Hypertensive Patients Research Articles

Identification of a gene network driving the attenuated response to lipopolysaccharide of monocytes from hypertensive coronary artery disease patients.

The impact of cardiovascular disease (CVD) risk factors, encompassing various biological determinants and unhealthy lifestyles, on the functional dynamics of circulating monocytes-a pivotal cell type in CVD pathophysiology remains elusive. In this study, we aimed to elucidate the influence of CVD risk factors on monocyte transcriptional responses to an infectious stimulus. We conducted a comparative analysis of monocyte gene expression profiles from the CTMM - CIRCULATING CELLS Cohort of coronary artery disease (CAD) patients, at baseline and after lipopolysaccharide (LPS) stimulation. Gene co-expression analysis was used to identify gene modules and their correlations with CVD risk factors, while pivotal transcription factors controlling the hub genes in these modules were identified by regulatory network analyses. The identified gene module was subjected to a drug repurposing screen, utilizing the LINCS L1000 database. Monocyte responsiveness to LPS showed a highly significant, negative correlation with blood pressure levels (ρ< -0.4; P<10-80). We identified a ZNF12/ZBTB43-driven gene module closely linked to diastolic blood pressure, suggesting that monocyte responses to infectious stimuli, such as LPS, are attenuated in CAD patients with elevated diastolic blood pressure. This attenuation appears associated with a dampening of the LPS-induced suppression of oxidative phosphorylation. Finally, we identified the serine-threonine inhibitor MW-STK33-97 as a drug candidate capable of reversing this aberrant LPS response. Monocyte responses to infectious stimuli may be hampered in CAD patients with high diastolic blood pressure and this attenuated inflammatory response may be reversed by the serine-threonine inhibitor MW-STK33-97. Whether the identified gene module is a mere indicator of, or causal factor in diastolic blood pressure and the associated dampened LPS responses remains to be determined.

Investigating the Association between Coronary Artery Disease and the Liver Fibrosis-4 Index in Patients Who Underwent Coronary Computed Tomography Angiography: A Cross-Sectional Study.

Liver fibrosis scores, indicative of hepatic scarring, have recently been linked to coronary artery disease (CAD). We investigated the association between CAD and the fibrosis-4 index (FIB-4I) in patients who underwent coronary computed tomography angiography (CCTA). This study included 1244 patients who were clinically suspected of having CAD. The presence or absence of CAD was the primary endpoint. FIB-4I was higher in the CAD group than in the non-CAD group (1.95 ± 1.21 versus [vs.] 1.65 ± 1.22, p < 0.001). FIB-4I was also higher in the hypertension (HTN) group than in the non-HTN group (1.90 ± 1.32 vs. 1.60 ± 0.98, p < 0.001). In all patients, high FIB-4I (≥2.67) was a predictor of presence of CAD (odds ratio [OR]: 1.92, 95% confidence interval [CI]: 1.30-2.83, p = 0.001), and low FIB-4I (≤1.29) was proven to be a predictor of absence of CAD (OR: 0.65, 95% CI: 0.48-0.88, p = 0.006). In the HTN group, high and low FIB-4I levels, were found to be predictors for CAD (OR: 2.01, 95% CI: 1.26-3.21, p < 0.001 and OR: 0.65, 95% CI: 0.45-0.94, p < 0.022, respectively), in particular. FIB-4I may serve as a diagnostic indicator of the presence or absence of CAD in hypertensive patients undergoing CCTA.

Triglyceride glucose index is associated with obstructive coronary artery disease in hypertensive patients

BackgroundHypertension is a leading risk of coronary artery disease (CAD). Triglyceride glucose index (TyG) is a surrogate of insulin resistance (IR). Few studies explore the association between TyG and the incidence of obstructive CAD (OCAD) in hypertensive patients.MethodsWe retrospectively screened 1841 hypertensive subjects who were free of a history of CAD and underwent coronary computed tomography angiography (CCTA) because of chest pain. TyG index was calculated as ln (fasting TG [mg/dL] * fasting glucose [mg/dL]/2). The outcome of this research was OCAD, which was defined as the presence of diameter stenosis ≥ 50% in any of the four major epicardial coronary arteries detected on CCTA.ResultsA total of 310 (16.8%) patients developed obstructive CAD. The restricted cubic spline (RCS) analysis showed a J-shaped relationship between TyG and OCAD and the OR for OCAD increased as the TyG rose over 8.61 (OR perSD) 1.64, 95% CI 1.13–2.54, p = 0.008). After full adjustments for confounding covariates, patients with TyG index in tertile 3 (T3) had 2.12 times (95% CI 1.80 to 3.81) and in T2 had 2.01 times (95% CI 1.40 to 2.88) as high as the risk of OCAD compared with patients in T1 (p for trend = 0.001). When regarding TyG as a continuous variable, 1-SD increase elevated 49% (OR (95%CI), 1.49 (1.30–1.74)) risk of obstructive CAD (p = 0.007). This positive effect was still consistent across the subgroups (p for interaction > 0.05).ConclusionTyG index was associated with the incidence of obstructive CAD in hypertensive patients.

Association of interleukin 6 and uric acid levels in patients with type 2 diabetes mellitus.

Type 2 Diabetes Mellitus (T2DM) patients with coronary artery disease (CAD) coupled with hypertension (HTN) are leading cause of morbidity and mortality. Association of Interleukin 6 and uric acid levels can be used for early detection of CAD in patients with T2DM. This cross sectional study included 120 study participants, were sub grouped into three Group 1: controls (n=30), Group 2: CAD, HTN without T2DM (n=30) and Group 3: CAD, HTN with T2DM (n=30). Basic biochemical, clinical and experimental parameters were analysed and recorded for all the study subjects. The statistical analysis was done by using the SPSS 20.0. Individuals with CAD, HTN with T2DM had higher BMI, weight, SBP, and DBP levels than patients CAD, HTN without diabetes and controls. In CAD, HTN with T2DM study participants has been found to have higher serum levels of inflammatory cytokines like IL-6 and uric acids when compared to CAD, HTN without T2DM and controls. IL6 was significantly positive association with uric acid and negative association with age and HDL. These findings demonstrated a statistically significant positive connection between IL-6, and uric acid concentrations. The identified elevated levels of inflammatory cytokines and uric acids in type 2 diabetic and hypertensive CAD patients may aid in the identification of patients at higher risk.

Correlation of inflammatory cytokines and uric acid levels in coronary artery disease with and without type 2 diabetes mellitus.

Serum levels of inflammatory cytokines such as IL-6, high-sensitivity C-reactive protein as well as uric acids have been considered as predictors of severe outcomes in patients with coronary artery disease (CAD) associated with hypertension (HTN) and Type 2 Diabetes Mellitus (T2DM). Anthropometric parameters were recorded and measured the levels of major risk factors in 80 patients with hypertension, coronary artery disease with and without Type 2 diabetes mellitus and 40 healthy controls were included. Comparison were performed by classifying the study subjects into 3 groups namely- Group I: Controls (n=40); Group II: HTN, CAD without T2DM(n=40); and Group III: HTN,CAD with T2DM(n=40).The values of BMI, weight, SBP, DBP were greater in patients with T2DM CAD group when compared to without diabetes group. Data shows that there is a positive correlation between IL-6, hs-CRP and uric acid concentrations and are statistically significant. The evaluated high levels of inflammatory cytokines and uric acids in hypertensive CAD patients with diabetes might be helpful in the diagnosis of patients at greater risk.

Prevalence and impact of high BMI in CAD patients

Abstract Funding Acknowledgements Type of funding sources: None. Background High body mass index (BMI) is a precursor to coronary artery disease (CAD) and an aggravator of the other co-existing CAD risk factors such as diabetes and hypertension. Lifestyle changes (e.g. balanced diet and exercise) in patients with high BMI are usually overlooked, although they contribute positively to prevention and improvement of CAD. Purpose The aim of this study is to calculate the prevalence of overweight and obesity in known CAD patients in both genders, in correlation with diabetes, hypertension, exercise and diet in CAD patients and to compare the findings to EUROASPIRE IV conducted in 2015 (1). Methods This study retrospectively included 362 patients (88% male; mean age 67 years) with a history of CAD (MI, PCI or CABG) from the registry of Cyprus heart survey in a hospital, in Nicosia from 2011 to 2014. Age, gender, date of myocardial infarction event, date of PCI or CABG surgery as well as CAD risk factors such as BMI, exercise, diet, hypertension and diabetes were noted on their visit to the cardiac clinic. Results Our study showed an overall similarity in BMI prevalence across both genders. The prevalence increased from 17.7% in patients with normal BMI (18.5-24.9) to the highest CAD prevalence of 49.2% which was seen in overweight (BMI = 25 –29.9) patients. However, there was a drop in the prevalence of obese (BMI = 30+) patients to 32.9%. This is supported by EUROASPIRE IV (1) which highlighted that CAD prevalence was higher in overweight patients (male = 83%; female = 80%) than obese patients (male = 36%; female = 44%) by nearly 2-fold. Furthermore, within the higher-than-normal BMIs, we recognized more non-diabetic CAD patients (115 overweight; 67 obese) in our study than diabetic CAD patients (62 overweight; 55 obese). On the contrary, hypertensive CAD patients (106 overweight; 80 obese) were more frequent than non-hypertensive CAD patients (71 overweight; 43 obese). Overweight patients split in nearly half when it came to exercise and diet (96 exercise, 82 do not; 90 diet, 88 do not). While in obese patients there was a higher proportion of patients not exercising or following a diet (47 exercise, 72 do not; 32 diet, 87 do not). According to EUROASPIRE IV (1), obesity contributed to higher prevalence of diabetes as patients did not lose weight. Conclusion Overweight and obese patients make up a large percentage of CAD patients. High BMI had a negative additive effect with hypertension but not with diabetes on the risk prevention in CAD patients which mismatches with the EUROASPIRE IV (1) findings. Despite BMI being a modifiable risk factor, not adhering to a diet or exercise was noticed in overweight and obese patients, which in return weakens their prevention of CAD.

4-7CORONARY ARTERY DISEASE ALTER ON NOVEL CLASSIFICATION LEFT VENTRICULAR GEMOMETRY IN HYPERTENSIVE PATIENTS IN HASAN SADIKIN GENERAL HOSPITAL BANDUNG

Background: Coronary artery disease (CAD) was known to cause an increase in left ventricular mass and changes in cardiac dimensions in hypertensive patients. There is a novel classification of left ventricular (LV) geometry. Objective: To evaluate the impact of CAD on LV geometry (LV dilatation, hypertrophy, and concetricity) in hypertensive patients at the Hasan Sadikin General Hospital Bandung. Method: Between September and December 2019, 115 consecutive patients underwent trans-thoracal echocardiography examination in Hasan Sadikin General Hospital Bandung, who had suffered from hypertension. Hypertension was defined as resting systolic blood pressure ≥140mmHg and/or diastolic blood pressure ≥90mmHg or on antihypertensive therapy routinely. CAD was defined as the patients have a known history of CAD in the medical record. Patients were divided based on LV dilation (end-diastolic volume[EDV]/body surface area[BSA]&gt;75 ml/m2), LV hypertrophy (LVM/BSA&gt;115 and &gt;95 g/m2 on men and women respectively), and concentricity (RWT&gt;0.42;0.32–0.42;or&lt;0.32). Results: One-hundred-ten patients were included after excluding patients with incomplete data. Sixty patients (54.55%) were females, mean age was 56.95±11.54 years old. Forty patients was diagnosed CAD (36.36%), 70 patients non-CAD (63.63%). Dilation LV was found in 23 patients (20.9%); CAD vs non-CAD (15/40 (37,5%) vs 8/70 (11,8%)); p = 0,001. Hypertrophic LV was found in 70 patients (63.6%); CAD vs non-CAD (32/40 (80%) vs 38/70 (54.3%)); p = 0,008. Concentricity RWT &gt; 0,42 (60%), RWT 0,32–0,42 (31.8%), RWT &lt; 0,32 (8.2%). In CAD vs non-CAD (26/7/7 vs 40/28/2); p = 0,04. Conclusion: In hypertensive patients, CAD group has significant difference in LV dilatation, hypertrophy, and concentricity compared to it counterparts. Based on this novel classification, CAD in hypertensive patients might have an impact on its prognosis.

Therapeutic Approach to Hypertension Urgencies and Emergencies During Acute Coronary Syndrome.

Uncontrolled hypertension is one of the most common determinant for the persistently high burden of cardiovascular (CV) disease, mostly including coronary artery disease (CAD) and hospital admissions due to acute coronary events. Markedly high blood pressure (BP) levels are also frequently observed during the acute phase of coronary syndromes (both ST-segment and non-ST-segment elevation myocardial infarction and unstable angina). In particular, a sustained raise of BP levels above 180/110mmHg associated with acute cardiac organ damage, i.e. myocardial ischemia, represents a condition of hypertension emergency and requires rapid hospital admission, prompt pharmacological therapies and non-pharmacological interventions, aimed at restoring coronary flow and preserve vital myocardium. Diagnosis of CAD in hypertensive patients may often be complicated by the concomitant presence of electrocardiographic abnormalities, such as ST-segment depression (at rest or during exercise), which may occur even in the absence of coronary atherosclerosis. Thus, proper identification of CADmay result difficult to perform in the setting of clinical practice, mostly in the presence of left ventricular hypertrophy. In this review, we will briefly discuss diagnostic protocols and pharmacological strategies that can be applied in a setting of hypertension emergency with acute cardiac organ damage in the light of the currently available evidence and recommendations from recent guidelines on hypertension management and control.

Evaluation of the Role of -137G/C Single Nucleotide Polymorphism (rs187238) and Gene Expression Levels of the IL-18 in Patients with Coronary Artery Disease.

Interleukin-18 (IL-18) is a proinflammatory and proatherogenic cytokine, and its genetic variations may contribute to the development of coronary artery disease (CAD). We sought to investigate the role of -137G/C polymorphism and gene expression levels of IL-18 in patients with CAD. The study population included 100 patients with angiographically proven CAD and 100 matched controls. Total RNA and DNA were extracted from leukocytes using appropriate kits. The genotype of -137G/C polymorphism and gene expression level of IL-18 was determined using allele-specific polymerase chain reaction (PCR) and real-time (RT)-PCR assay, respectively. The genotypic and allelic distribution of IL-18 -137G/C polymorphism was not significantly different between the two groups (p > 0.050). Moreover, the -137G/C polymorphism did not increase the risk of CAD in dominant and recessive genetic models (p > 0.050). However, subgroup analysis of CAD patients revealed that the IL-18 -137G/C polymorphism was significantly associated with increased risk of CAD in hypertensive patients (odds ratio (OR) = 7.51; 95% confidence interval (CI): 1.24-25.17; p = 0.019) and smokers (OR = 4.90; 95% CI: 1.21-19.70; p = 0.031) but not in the diabetic subpopulation (p = 0.261). The genotype distribution of IL-18 -137G/C genetic polymorphism was significantly different among patients with one, two, and three stenotic vessels (p < 0.050). The gene expression level of IL-18 was significantly higher in the CAD group than the control group (p < 0.001). Moreover, the carriers of CC genotype had significantly lower gene expression levels of IL-18 than carriers of GG genotype (p < 0.050). The -137G/C polymorphism of IL-18 may be associated with the CAD risk in hypertensive and smoker subgroup of CAD patients. The -137G/C polymorphism seems to play an important role in determining the severity of CAD. Increased IL-18 gene expression level is a significant risk factor for the development of CAD. The CC genotype of -137G/C polymorphism is associated with lower IL-18 gene expression levels.

Cluster analysis: a new approach for identification of underlying risk factors for coronary artery disease in essential hypertensive patients

Grading of essential hypertension according to blood pressure (BP) level may not adequately reflect clinical heterogeneity of hypertensive patients. This study was carried out to explore clinical phenotypes in essential hypertensive patients using cluster analysis. This study recruited 513 hypertensive patients and evaluated BP variations with ambulatory blood pressure monitoring. Four distinct hypertension groups were identified using cluster analysis: (1) younger male smokers with relatively high BP had the most severe carotid plaque thickness but no coronary artery disease (CAD); (2) older women with relatively low diastolic BP had more diabetes; (3) non-smokers with a low systolic BP level had neither diabetes nor CAD; (4) hypertensive patients with BP reverse dipping were most likely to have CAD but had least severe carotid plaque thickness. In binary logistic analysis, reverse dipping was significantly associated with prevalence of CAD. Cluster analysis was shown to be a feasible approach for investigating the heterogeneity of essential hypertension in clinical studies. BP reverse dipping might be valuable for prediction of CAD in hypertensive patients when compared with carotid plaque thickness. However, large-scale prospective trials with more information of plaque morphology are necessary to further compare the predicative power between BP dipping pattern and carotid plaque.

Relationships between use of statins and arterial stiffness in normotensive and hypertensive patients with coronary artery disease

Background Statins improve arterial stiffness in patients with coronary artery disease (CAD). Hypertension is a predominant contributor of arterial stiffening. However, the influence of hypertension on the effect of statins for improving arterial stiffness in CAD patients has seldom been investigated. Therefore, in this study, we investigated the relationships between statin use and arterial stiffness in normotensive and hypertensive CAD patients. Methods Brachial-ankle pulse wave velocity (ba-PWV) was measured in 437 patients, including 220 hypertensive CAD patients (121 used statins, 99 did not) and 217 normotensive CAD patients (105 used statins, 112 did not). The normotensive and hypertensive CAD patients were matched according to age, sex, and body mass index (BMI). Results In the normotensive and hypertensive CAD patients, lipid profiles were significantly improved in the statin group compared with the non-statin group. No significant differences in the administered statins (i.e., atorvastatin, simvastatin, rosuvastatin, and pravastatin) and statin therapy duration were found between normotensive and hypertensive CAD patients (all P&gt;0.05). No significant correlation of ba-PWV and statin therapy duration was found in all CAD patients, normotensive CAD patients, or hypertensive CAD patients (all P&gt;0.05). ba-PWV in the statin group was significantly lower than that in the non-statin group in normotensive CAD patients ((1331.68±167.52) cm/s vs. (1468.61±244.54) cm/s, P=0.002) but not in hypertensive CAD patients (P&gt;0.05). In multiple linear regression analyses, statin therapy was significantly associated with ba-PWV after adjusting for confounding variables in normotensive CAD patients (P=0.018) but not in hypertensive CAD patients (P&gt;0.05). Conclusions Statins may significantly improve arterial stiffness in CAD patients, and hypertension may probably influence the effectiveness of statin therapy in improving arterial stiffness in this population. Further studies are required to investigate the effect of statins on arterial stiffness in normotensive and hypertensive CAD patients.

Mortality Implications of Angina and Blood Pressure in Hypertensive Patients With Coronary Artery Disease: New Data From Extended Follow‐up of the International Verapamil/Trandolapril Study (INVEST)

Angina and hypertension are common in patients with coronary artery disease (CAD); however, the effect on mortality is unclear. We conducted this prespecified analysis of the International Verapamil/Trandolapril Study (INVEST) to assess relationships between angina, blood pressure (BP), and mortality among elderly, hypertensive CAD patients. Angina and elevated BP will be associated with higher mortality. Extended follow-up was performed using the National Death Index for INVEST patients in the United States (n = 16 951). Based on angina history at enrollment and during follow-up visits, patients were divided into groups: persistent angina (n = 7184), new-onset angina (n = 899), resolved angina (n = 4070), and never angina (n = 4798). Blood pressure was evaluated at baseline, during drug titration, and during follow-up on-treatment. On-treatment systolic BP was classified as tightly controlled (<130 mm Hg), controlled (130-139 mm Hg), or uncontrolled (≥140 mm Hg). A Cox proportional hazards model was created adjusting for age, heart failure, diabetes, renal impairment, myocardial infarction, stroke, and smoking. The angina groups and BP control groups were compared using the never-angina group as the reference. Only in the persistent-angina group was a significant association with mortality observed, with an apparent protective effect (hazard ratio: 0.82, 95% confidence interval: 0.75-0.89, P < 0.0001). Uncontrolled BP was associated with increased mortality risk (hazard ratio: 1.29, 95% confidence interval: 1.20-1.40, P < 0.0001), as were several other known cardiovascular risk factors. In hypertensive CAD patients, persistent angina was associated with lower mortality. The observed effect was small compared with other cardiovascular risk factors, such as BP, which were associated with increased mortality.

Renal Artery Stenosis Predicts Coronary Artery Disease in Patients with Hypertension

In hypertensive patients with indication of renal arteriography to investigate renal artery stenosis (RAS) there are no recommendations regarding when to investigate coronary artery disease (CAD). Moreover, the predictors of CAD in patients with RAS are not clear. We aimed to evaluate the frequency and the determinants of CAD in hypertensive patients referred to renal angiography. Eighty-two consecutive patients with high clinical risk suggesting the presence of RAS systematically underwent renal angiography and coronary angiography during the same procedure. Significant arterial stenosis was defined by an obstruction≥70% to both renal and coronary territories. Significant CAD was present in 32/82 (39%) and significant RAS in 32/82 (39%) patients. Both CAD and RAS were present in 25.6% from the 82 patients. Patients with severe CAD were older (63±12 vs. 56±13 years; p = 0.03) and had more angina (41 vs. 16%; p = 0.013) compared to patients without severe CAD. Significant RAS was associated with an increased frequency of severe CAD compared to patients without significant RAS (66% vs. 22%, respectively; p<0.001). Myocardial scintigraphy showed ischemia in 21.8% of the patients with CAD. Binary logistic regression analysis showed that RAS≥70% was independently associated with CAD≥70% (OR: 11.48; 95% CI 3.2–40.2; p<0.001), even in patients without angina (OR: 13.48; 95%CI 2.6–12.1; p<0.001). Even considering a small number of patients with significant RAS, we conclude that in hypertensive patients referred to renal angiography, RAS≥70% may be a strong predictor of severe CAD, independently of angina, and dual investigation should be considered.

Comparing marginal structural models to standard methods for estimating treatment effects of antihypertensive combination therapy

BackgroundDue to time-dependent confounding by blood pressure and differential loss to follow-up, it is difficult to estimate the effectiveness of aggressive versus conventional antihypertensive combination therapies in non-randomized comparisons.MethodsWe utilized data from 22,576 hypertensive coronary artery disease patients, prospectively enrolled in the INternational VErapamil-Trandolapril STudy (INVEST). Our post-hoc analyses did not consider the randomized treatment strategies, but instead defined exposure time-dependently as aggressive treatment (≥3 concomitantly used antihypertensive medications) versus conventional treatment (≤2 concomitantly used antihypertensive medications). Study outcome was defined as time to first serious cardiovascular event (non-fatal myocardial infarction, non-fatal stroke, or all-cause death). We compared hazard ratio (HR) estimates for aggressive vs. conventional treatment from a Marginal Structural Cox Model (MSCM) to estimates from a standard Cox model. Both models included exposure to antihypertensive treatment at each follow-up visit, demographics, and baseline cardiovascular risk factors, including blood pressure. The MSCM further adjusted for systolic blood pressure at each follow-up visit, through inverse probability of treatment weights.Results2,269 (10.1%) patients experienced a cardiovascular event over a total follow-up of 60,939 person-years. The HR for aggressive treatment estimated by the standard Cox model was 0.96 (95% confidence interval 0.87-1.07). The equivalent MSCM, which was able to account for changes in systolic blood pressure during follow-up, estimated a HR of 0.81 (95% CI 0.71-0.92).ConclusionsUsing a MSCM, aggressive treatment was associated with a lower risk for serious cardiovascular outcomes compared to conventional treatment. In contrast, a standard Cox model estimated similar risks for aggressive and conventional treatments.Trial registrationClinicaltrials.gov Identifier: NCT00133692

Myocardial perfusion scintigraphy and echocardiography for detecting coronary artery disease in hypertensive patients: a meta-analysis

This meta-analysis summarized the accuracy of stress myocardial perfusion scintigraphy (MPS) and stress echocardiography for the diagnosis of coronary artery disease (CAD) in patients with arterial hypertension. We searched for studies in which stress MPS or stress echocardiography were performed to detect CAD in hypertensive patients, with coronary angiography used as the reference test, published from January 1980 to December 2010. Studies performed in patients with known CAD, acute coronary syndrome and previous revascularization procedures were excluded. Of 1,263 studies, 13 met the inclusion criteria. Pooled summary estimates showed that stress MPS had a sensitivity of 0.90 [95% confidence interval (CI) 0.82-0.95] and a specificity of 0.63 (95% CI 0.53-0.72). For stress MPS, the area under the curve (AUC) at the summary receiver-operating characteristic (SROC) graph was 0.83 (95% CI 0.80-0.86). At meta-regression analysis, the presence of positive stress electrocardiography as inclusion criterion was the only significant effect modifier (p < 0.01). Pooled summary estimates showed that stress echocardiography had a sensitivity of 0.77 (95% CI 0.69-0.83) and a specificity of 0.89 (95% CI 0.83-0.93). For stress echocardiography, the AUC at SROC was 0.91 (95% CI 0.88-0.93). At the meta-regression analysis no significant effect modifier was detected. MPS has high sensitivity for detecting CAD in hypertensive patients, with specificity comparable to that reported in the general population, whereas stress echocardiography shows higher specificity but substantially reduced sensitivity compared to MPS.

Blood Pressure and Outcomes in Very Old Hypertensive Coronary Artery Disease Patients: An INVEST Substudy

Background Our understanding of the growing population of very old patients (aged ≥80 years) with coronary artery disease and hypertension is limited, particularly the relationship between blood pressure and adverse outcomes. Methods This was a secondary analysis of the INternational VErapamil SR-Trandolapril STudy (INVEST), which involved 22,576 clinically stable hypertensive coronary artery disease patients aged ≥50 years. The patients were grouped by age in 10-year increments (aged ≥80, n = 2180; 70–<80, n = 6126; 60–<70, n = 7602; <60, n = 6668). Patients were randomized to either verapamil SR- or atenolol-based treatment strategies, and primary outcome was first occurrence of all-cause death, nonfatal myocardial infarction, or nonfatal stroke. Results At baseline, increasing age was associated with higher systolic blood pressure, lower diastolic blood pressure, and wider pulse pressure ( P <.001). Treatment decreased systolic, diastolic, and pulse pressure for each age group. However, the very old retained the widest pulse pressure and the highest proportion (23.6%) with primary outcome. The adjusted hazard ratio for primary outcomes showed a J-shaped relationship among each age group with on-treatment systolic and diastolic pressures. The systolic pressure at the hazard ratio nadir increased with increasing age, highest for the very old (140 mm Hg). However, diastolic pressure at the hazard ratio nadir was only somewhat lower for the very old (70 mm Hg). Results were independent of treatment strategy. Conclusion Optimal management of hypertension in very old coronary artery disease patients may involve targeting specific systolic and diastolic blood pressures that are higher and somewhat lower, respectively, compared with other age groups.

Impact of Long-Acting Calcium Channel Blockers on the Prognosis of Patients with Coronary Artery Disease with and without Chronic Kidney Disease: A Comparison of Three Drugs

Calcium channel blockers (CCBs) can prevent cardiovascular events in patients with coronary artery disease (CAD). This study looked retrospectively at the prognosis of CAD in hypertensive patients with CAD who had undergone a coronary angiograph, had been given a CCB (benidipine [n = 66], amlodipine [n = 45], or long-acting nifedipine [n = 31]) on hospital discharge and were then followed up for a mean +/- SD of 5.2 +/- 2.9 years. Systolic/diastolic blood pressure for all 142 patients decreased significantly from a mean +/- SD of 137 +/- 20/74 +/- 15 mmHg to 129 +/- 20/71 +/- 12 mmHg. Major adverse cardiovascular events (MACE) occurred in 15 patients. Chronic kidney disease (CKD) was a significant risk factor for MACE (hazard ratio 2.35, 95% confidence intervals 1.45, 3.80). Benidipine was superior to nifedipine in preventing MACE in patients both with and without CKD. In conclusion, benidipine and amlodipine reduced the frequency of MACE in hypertensive patients with CAD, particularly in those with complicating CKD.

242 Cardiovascular Benefits Of Perindopril In Coronary Artery Disease Patients With Hypertension. New Findings From The Europa Study According Jnc-7 Definition Of Hypertension

In the EUROPA study, perindopril 8 mg/day significantly reduced the combined primary end point (PEP) of cardiovascular death, nonfatal myocardial infarction (MI), and/or resuscitated cardiac arrest by 20%, compared with placebo, after 4.2 years in 12 218 patients with stable coronary artery disease (CAD) without heart failure. The aim of this new analysis is to calculate the benefits of perindopril 8 mg/day in CAD patients with hypertension according to JNC-7 cutoff. In EUROPA, 7064 (57.8%) patients were hypertensive with SBP/DBP ≥ 140/90 mm Hg or current antihypertensive therapy. The baseline characteristics of these patients were not different from the whole EUROPA population: 63% had a previous MI (n=4469) and 54% were previously revascularized (n=3839). In EUROPA patients with hypertension, the incidence of the PEP with perindopril (n=3506) and placebo (n=3558) was 9% and 11.1%, respectively. The relative risk reduction (RRR) of PEP with perindopril was 18.6% (95% CI [6.9; 30.8]; P=0.004). Among EUROPA patients with hypertension, the RRR of fatal and nonfatal MI was 26.4% (95% CI [11.6; 38.8]; P=0.001), with a rate of 5.6% and 7.6% with perindopril and placebo, respectively. This reduction in risk for MI was consistent whether the patients had had previous MI (RRR, 32.6% [95% CI (16; 45.9); P<0.001]) or revascularization (RRR, 30.2%, [95% CI (7.7; 47.2); P=0.011]). Finally, heart failure was significantly reduced with perindopril (1.2%) versus placebo (2%) by 40.2% (95% CI [12.4; 59.2]; P=0.008). In these CAD patients with hypertension, discontinuation for hypotension was particularly low with perindopril (0.6%), similar to placebo (0.2%), confirming the safety of high-dose perindopril (8 mg/day) in terms of BP lowering. In the EUROPA study, the benefit with perindopril 8 mg/day was consistent among hypertensive CAD patients, even in case of previous MI and/or revascularization. These results are in line with the 2006 ESC guidelines on the management of stable angina pectoris, endorsing the use of this dose of perindopril, which is of proven efficacy in this indication (Class 1, level of evidence A)

Azelnidipine and Amlodipine Anti-Coronary Atherosclerosis Trial in Hypertensive Patients Undergoing Coronary Intervention by Serial Volumetric Intravascular Ultrasound Analysis in Juntendo University (ALPS-J)

Many trials have shown that calcium channel blockers (CCBs) can reduce the cardiovascular (CV) events in patients with coronary artery disease (CAD). The mechanisms of this effect could be associated with plaque regression due to the anti-atherosclerotic properties of CCBs. The goal of this study is to determine the effects of CCB on volumetric quantitative changes of coronary plaques accessed by intravascular ultrasound (IVUS). To confirm this hypothesis, a multicenter randomized trial of CCBs treatment with azelnidipine or amlodipine will be conducted in hypertensive CAD patients undergoing elective percutaneous coronary intervention (PCI). Patients who have hypertension and are scheduled for PCI will be enrolled. Subjects will be randomized to azelnidipine or amlodipine and observed for 48 weeks. The primary endpoint will be the percent change of coronary plaque volume. The secondary endpoint will include inflammatory markers, antioxidant activity, and incidence of composite cardiovascular events. In this study, we will investigate the improvement of coronary plaque with IVUS by treatment with two dihydropyridine CCBs in hypertensive patients undergoing elective PCI. This result will lead to the discovery of more effective drug therapy for inhibition of coronary events.

Systolic Blood Pressure and Subjective Well‐Being in Patients with Coronary Artery Disease

Limited information exists regarding the association between subjective well-being (SWB) and systolic blood pressure (SBP) among hypertensive patients with coronary artery disease (CAD). We tested the hypothesis that there is an association between SBP and SWB. We studied 22,576 hypertensive CAD patients > or = 50 years old in the INternational VErapamil SR-Trandolapril Study (INVEST), a randomized, blinded-endpoint trial of antihypertensive therapy in stable CAD patients. At each study visit, patients rated their SWB in the previous 4 weeks as "excellent," "good," "fair," or "poor" prior to SBP recordings. The outcome measure was SWB of "fair" or "poor." A longitudinal analysis using generalized estimating equations was performed to assess the association between SBP and odds of reporting fair/poor SWB, controlling for baseline SWB of fair/poor and angina reported during the study. Patients with higher SBP had higher odds of reporting fair/poor SWB. Specifically, compared with patients with SBP of < or = 120, patients with SBP 140-150 > 150 - < or = 160 and > 160 had about 90% and 2.5 times greater odds of feeling fair/poor, respectively (adjusted odds ratio [OR]: 1.5990, 95% confidence interval [CI]: 1.81-2.00 and adjusted OR: 2.53, 95% CI: 2.41-2.66). Those who reported angina in the 4 wks prior to a protocol visit had 2.2 times greater odds of reporting fair/poor SWB (adjusted OR: 2.2, 95% CI: 2.13-2.27). Female gender, black race, history of smoking, diabetes, myocardial infarction, stroke, and cancer also increased the odds of reporting fair/poor SWB. Among hypertensive CAD patients, higher on-treatment SBP is associated with greater odds of fair/poor SWB during follow-up.