New BP Goals for Patients with Hypertension and CAD
JACC in a Flash | Patients with hypertension and vascular diseases should aim for a blood pressure target of less than 140/90 mm Hg to prevent myocardial infarction (MI) and stroke, according to a new scientific statement released March 31, 2015 by the ACC, American Heart Association, and American Society of Hypertension, and simultaneously published in JACC.
The statement, which is an update to the 2007 article "Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease," addresses the prevention of cardiovascular events, and sets blood pressure goals for patients with hypertension and coronary artery disease (CAD). It notes that for those patients who have already experienced a stroke, MI or transient ischemic attack, or those who have other cardiovascular conditions, a blood pressure target of less than 130/80 mm Hg may be more appropriate.
The statement further explains that blood pressure lowering can and should be done safely. Most patients will not encounter problems with standard medications, such as a beta-blocker by itself or in combination with another drug. However, clinicians should exercise caution in treating patients with coronary artery blockages and hypertension, lowering blood pressure slowly over time. The statement advises that these patients not lower their diastolic blood pressure to less than 60 mm Hg, especially if the patient is more than 60 years old. Based on evidence from clinical trials and research, the statement makes specific anti-hypertensive medication recommendations for patients with various types of cardiovascular disease.
"In the spectrum of drugs available for the treatment of hypertension, beta-blockers assume center stage in patients with CAD," said Clive Rosendorff, MD, PhD, chair of the writing committee, professor of medicine at the Icahn School of Medicine at Mount Sinai Medical Center in New York, and director of graduate medicine education at the Veterans Administration in the Bronx. "In addition to treating hypertension, this statement also recognizes the importance of modifying other risk factors for MI, stroke and other vascular disease, including abdominal obesity, abnormal cholesterol, diabetes and smoking."
- Rosendorff C, Lackland DT, Allison M, et al. J Am Coll Cardiol. 2015;doi:10.1016/j.jacc.2015.02.038.
10 points to remember about this AHA/ACC/ASH Scientific Statement
- Nearly one fourth of the adult population of the U.S. has hypertension. Blood pressure (BP) lowering in patients with hypertension produces robust reductions in cardiovascular risk.
- A 10 mm Hg lower usual systolic BP is associated with a 50%-60% lower risk of stroke death and a 40%-50% lower risk of death resulting from CAD.
- The following pathophysiologic mechanisms interact with genetic, demographic, and environmental factors to determine whether an individual may develop hypertension and related CAD: increased activity of the sympathetic nervous system and renin-angiotensin-aldosterone system, deficiencies in the release or activity of vasodilators, changes in natriuretic peptide concentrations, increased expression of growth factors and inflammatory cytokines, increased vascular stiffness, and endothelial dysfunction.
- The < 140/90 mm Hg BP target is reasonable for the secondary prevention of cardiovascular disease in patients with hypertension and CAD. A lower target BP of < 130/80 mm Hg may be appropriate in some individuals with CAD or those with previous myocardial infarction (MI), stroke, or transient ischemic attack, or CAD risk equivalents (carotid artery disease, peripheral arterial disease, or abdominal aortic aneurysm).
- A BP goal of < 150/90 mm Hg is recommended in those who are > 80 years of age. The writers of the Scientific Statement have suggested a target of < 140/90 mm Hg for the 65- to 79-year age group.
- Myocardial perfusion occurs almost exclusively during diastole. Accordingly, and in patients with an elevated diastolic BP and CAD with evidence of myocardial ischemia, the BP should be lowered slowly.
- Decreases in diastolic BP < 60 mm Hg should be made with caution in any patient with diabetes mellitus or who is > 60 years of age.
- While there has been considerable controversy regarding the appropriateness of beta-blocker therapy as first-line therapy in hypertension, there is convincing evidence for the use of beta-blockade in those patients with angina, prior MI, or heart failure with reduced ejection fraction.
- Patients with hypertension and chronic stable angina should be treated with a regimen that includes the following: beta-blocker in those with a history of MI; angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker if there is prior MI, left ventricular systolic dysfunction, diabetes mellitus, or chronic kidney disease; and a thiazide or thiazide-like diuretic. In patients with acute coronary syndrome, a short-acting β1-selective beta-blocker without intrinsic sympathomimetic activity (metoprolol tartrate or bisoprolol) should be the initial therapy of hypertension, and should be initiated orally within 24 hours of presentation, provided there is no contraindication.
- The following are drugs to avoid in patients with hypertension and HF with reduced ejection fraction: non-dihydropyridine calcium channel blockers (such as verapamil or diltiazem), clonidine, moxonidine, and hydralazine without a nitrate. Regarding hydralazine monotherapy, there is a lack of randomized trial evidence to support the use of hydralazine without a nitrate in the treatment of essential hypertension, and hydralazine alone may provoke angina.
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