Scientific Statement on Treatment of Hypertension for Coronary Artery Disease | Ten Points to Remember

Rosendorff C, Lackland DT, Allison M, et al.
Treatment of Hypertension in Patients With Coronary Artery Disease: A Scientific Statement From the American Heart Association, American College of Cardiology, and American Society of Hypertension. J Am Coll Cardiol 2015;Mar 31:[Epub ahead of print].

The following are 10 points to remember about this Scientific Statement regarding the treatment of hypertension in patients with coronary artery disease (CAD):

  1. Nearly one fourth of the adult population of the United States 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.
  2. 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.
  3. The <140/90 mm Hg BP target is reasonable for the secondary prevention of cardiovascular disease in patients with hypertension and CAD.
  4. 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).
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.

Clinical Topics: Acute Coronary Syndromes, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Stable Ischemic Heart Disease, Hypertension, Chronic Angina

Keywords: Acute Coronary Syndrome, Adrenergic beta-Antagonists, Angina Pectoris, Angina, Stable, Angiotensin-Converting Enzyme Inhibitors, Blood Pressure, Hypertension, Coronary Artery Disease, Calcium Channel Blockers, Clonidine, Diabetes Mellitus, Diastole, Hydralazine, Metabolic Syndrome X, Myocardial Infarction, Natriuretic Peptides, Risk Factors, Secondary Prevention, Stroke, Thiazides, Vascular Stiffness

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