In hypertensive patients with coronary artery disease (CAD) over the age 60 years old, achieving the blood pressure target of 140 to <150 mm Hg as recommended by some members of the Eighth Joint National Committee in late 2013, was associated with less benefit than the previously recommended target of <140 mm Hg, according to results from the INVEST Trial published on Aug. 18 in the Journal of the American College of Cardiology.

Additional Resources New ACC/AHA/CDC Scientific Advisory on an Effective Approach to High BP Control

The study randomized 8,354 patients 60 years of age or older with CAD and baseline systolic BP >150 mm Hg to a treatment strategy based on either atenolol or verapamil-SR (sustained release). Overall findings found that patients with systolic BP of <140 mm Hg was associated with numerically the lowest rate of primary and most secondary cardiovascular outcomes compared to those with systolic BP of less than or equal to 140 mm Hg, without any increase in adverse experiences.

Study investigators also noted that rates of the overall primary outcome and all-cause mortality were similar when INVEST patients who achieved on-treatment systolic BP of <140 mm Hg were compared with those who achieved on-treatment BP of 140 to 150 mm Hg. However, patients with BP < 140 mm Hg had significantly fewer strokes. Findings also showed that those whose on-treatment BP remained >150 mm Hg had significant increases in the primary outcome of all-cause death, nonfatal myocardial infarction (MI), or nonfatal stroke, as well as secondary outcomes of all-cause mortality, cardiovascular mortality, total MI, nonfatal MI, total stroke, nonfatal stroke, heart failure, or revascularization.

"These data provide important information to focus the risk-benefit discussion for patients with on-treatment BP in the 140 to 150 mm Hg range clearly on stroke prevention and on overall reduction of mortality for patients with on-treatment BP >150 mm Hg," the investigators said.

In a statement released by ACC President Patrick T. O'Gara, MD, FACC, and American Heart Association (AHA) President Elliott Antman, MD, FACC, both said the study supports the concerns raised by many stakeholders, including the ACC, the AHA and a number of the individual members of the 'JNC 8' panel, about the panel's 2013 recommendations to raise blood pressure targets in older patients. "This new research suggests that raising the threshold for treatment of hypertension in patients 60 years of age or older with coronary artery disease may be detrimental to the best interest of patients and the public," they said. " It underscores ongoing concerns about adopting the unofficial 2013 targets as proposed by the panel originally appointed to write JNC 8. The ACC and AHA, working with the NHLBI, are in the process of assembling the writing panel that will evaluate evidence from a variety of sources and provide a comprehensive update of the hypertension guideline."

Meanwhile, in an accompanying JACC editorial, Alan H. Gradman, MD, from Temple University School of Medicine, writes that his overall sense is that the JNC 8 panel recommendations are reasonable for patients with hypertension and CAD. He does note "that for patients with isolated systolic hypertension and an SBP in the 140s, clinical judgment will be required." He also suggests more intensive treatment for patients at increased risk of stroke. "Practitioners should carefully note the corollary recommendation given by the JNC 8 panel that 'if pharmacologic treatment for high BP results in lower achieved SBP (for example, <140 mmHg) and treatment is not associated with adverse effects on health or quality of life, treatment does not need to be adjusted,'" he writes.

Keywords: Judgment, Myocardial Infarction, Stroke, National Heart, Lung, and Blood Institute (U.S.), Quality of Life, Heart Failure, Verapamil, Hypertension

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