Current Atherosclerosis Reports

, Volume 12, Issue 2, pp 134–139 | Cite as

Evidence for Aggressive Blood Pressure–Lowering Goals in Patients with Coronary Artery Disease



Lowering blood pressure (BP) reduces the risk of major cardiovascular mortality and morbidity. Current consensus targets for BP reduction are less than 140/90 mm Hg in uncomplicated hypertension and less than 130/80 mm Hg in those patients with diabetes, chronic kidney disease, and coronary artery disease or in those who are at high risk for developing coronary artery disease (defined as a Framingham risk score of ≥ 10%). There is solid epidemiologic evidence for lower BP targets, supported by some clinical studies with surrogate end points. On the other hand, there are meager data from clinical trials using hard end points, and there is a concern that overly aggressive BP lowering, especially of diastolic BP, may impair coronary perfusion, particularly in patients with left ventricular hypertrophy and/or coronary artery disease. This review evaluates the evidence for the benefit of lower BP targets in hypertension management.


BP goals Coronary artery disease Hypertension Blood pressure J curve 


Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  1. 1.
    Elliott P: High blood pressure in the community. In Handbook of Hypertension, vol 20. Epidemiology of Hypertension. Edited by Bulpitt CJ. Amsterdam: Elsevier Science; 2000:1–18.Google Scholar
  2. 2.
    van den Hoogen PC, Feskens EJ, Nagelkerke NJ, et al.: The relation between blood pressure and mortality due to coronary heart disease among men in different parts of the world. Seven Countries Study Research Group. N Engl J Med 2000, 342:1–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Chobanian AV, Bakris GL, Black HR, et al.: Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003, 42:1406–1252.CrossRefGoogle Scholar
  4. 4.
    •• Rosendorff C, Black HR, Cannon CP, et al.: Treatment of hypertension in the prevention and management of ischemic heart disease. A Scientific Statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation 2007, 115:2761–2788. This is a comprehensive review of the management of hypertension to prevent the development of coronary heart disease, as well as a review of hypertension management in those patients with established coronary disease. The statement provides evidence and guidance on lowering BP in these patient populations.CrossRefPubMedGoogle Scholar
  5. 5.
    Steinberg BA, Bhatt DL, Mehta S, et al.: Nine-year trends in achievement of risk factor goals in the US and European outpatients with cardiovascular disease. Am Heart J 2008, 156:719–727.CrossRefPubMedGoogle Scholar
  6. 6.
    Izzo JL Jr, Gradman AH: Mechanisms and management of hypertensive heart disease: from left ventricular hypertrophy to heart failure. Med Clin North Am 2004, 88:1257–1270.CrossRefPubMedGoogle Scholar
  7. 7.
    Olsson RA, Bünger R: Metabolic control of coronary blood flow. Prog Cardiovasc Dis 1987, 29:369–387.CrossRefPubMedGoogle Scholar
  8. 8.
    Canty JM Jr: Coronary pressure-function and steady-state pressure-flow relations during autoregulation in the unanesthetized dog. Circ Res 1988, 63:821–836.PubMedGoogle Scholar
  9. 9.
    Rouleau JR, Simard D, Blouin A, et al.: Angiotensin inhibition and coronary autoregulation in a canine model of LV hypertrophy. Basic Res Cardiol 2002, 97:384–391.CrossRefPubMedGoogle Scholar
  10. 10.
    Canty JM Jr, Klocke FJ: Reduced regional myocardial perfusion in the presence of pharmacologic vasodilator reserve. Circulation 1985, 71:370–337.PubMedGoogle Scholar
  11. 11.
    Pepi M, Alimento M, Maltagliati A, Guazzi MD: Cardiac hypertrophy in hypertension. Repolarization abnormalities elicited by rapid lowering of pressure. Hypertension 1988, 11:84–91.Google Scholar
  12. 12.
    Wicker P, Tarazi RC: Coronary blood flow in left ventricular hypertrophy: a review of experimental data. Eur Heart J 1982, 3(Suppl A):111–118.Google Scholar
  13. 13.
    Duprez DA, Florea ND, Jones K, et al.: Beneficial effects of valsartan in asymptomatic individuals with vascular or cardiac abnormalities—the DETECTIV pilot study. J Am Coll Cardiol 2007, 50:835–839.CrossRefPubMedGoogle Scholar
  14. 14.
    Sipahi I, Tuzcu EM, Schoenhagen P, et al.: Effects of normal, pre-hypertensive, and hypertensive blood pressure levels on progression of coronary atherosclerosis. J Am Coll Cardiol 2006, 48:833–838.CrossRefPubMedGoogle Scholar
  15. 15.
    •• Howard BV, Roman MJ, Devereux RB, et al.: Effect of lower targets for blood pressure and ldl cholesterol on atherosclerosis in diabetes: the SANDS randomized trial. JAMA 2008, 299:1678–1689. This study shows that aggressive BP and lipid lowering resulted in regression of carotid IMT and a significant decrease in left ventricular mass in Native Americans.CrossRefPubMedGoogle Scholar
  16. 16.
    Verdecchia P, Staessen JA, Angeli F, et al.: Usual versus tight control of systolic blood pressure in non-diabetic patients with hypertension (Cardio-Sis): an open-label randomised trial. Lancet 2009, 374:525–533.CrossRefPubMedGoogle Scholar
  17. 17.
    SHEP Cooperative Research Group: Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: Final results of the Systolic Hypertension in the Elderly Program. JAMA 1991, 265:3255–3264.CrossRefGoogle Scholar
  18. 18.
    Staessen JA, Fagard R, Lutgarde T, et al.: Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet 1997, 350:757–764.CrossRefPubMedGoogle Scholar
  19. 19.
    Liu L, Wang JG, Gong L, et al.: Comparison of active treatment and placebo in older Chinese patients with isolated systolic hypertension. Systolic Hypertension in China (Syst-China) Collaborative Group. J Hypertens 1998, 16:1823–1829.CrossRefPubMedGoogle Scholar
  20. 20.
    Hansson L, Zanchetti A, Carruthers SG, et al.: Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998, 351:1755–1762.CrossRefPubMedGoogle Scholar
  21. 21.
    Estacio R, Jeffers B, Hiatt W, et al.: The effect of nisoldipine as compared with enalapril on cardiovascular outcomes in patients with non-insulin dependent diabetes and hypertension. N Engl J Med 1998, 338:645–652.CrossRefPubMedGoogle Scholar
  22. 22.
    UK Prospective Diabetes Study Group: Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. BMJ 1998, 317:713–720.Google Scholar
  23. 23.
    Vasan RS, Larson MG, Leip EP, et al.: Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med 2001, 345:1291–1297CrossRefPubMedGoogle Scholar
  24. 24.
    Erdogan D, Yildirim I, Ciftci O, et al.: Effects of normal blood pressure, prehypertension, and hypertension on coronary microvascular function. Circulation 2007, 115:593–599.CrossRefPubMedGoogle Scholar
  25. 25.
    Lewington S, Clarke R, Qizilbash N, et al.; Prospective Studies Collaboration: Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002, 360:1903–1913.CrossRefPubMedGoogle Scholar
  26. 26.
    Cruickshank JM.: Coronary flow reserve and the J curve relation between diastolic blood pressure and myocardial infarction. BMJ 1988, 297:1227–1230.CrossRefPubMedGoogle Scholar
  27. 27.
    Cruickshank JM, Thorp JM, Zacharias FJ: Benefits and potential harm of lowering high blood pressure. Lancet 1987, 1:581–584.CrossRefPubMedGoogle Scholar
  28. 28.
    Somes GW, Pahor M, Shorr RI, et al.: The role of diastolic blood pressure when treating isolated systolic hypertension. Arch Intern Med 1999, 159:2004–2009.CrossRefPubMedGoogle Scholar
  29. 29.
    Fagard R, Staessen J, Thijs L, et al.: On-treatment diastolic blood pressure and prognosis in systolic hypertension. Arch Intern Med 2007, 167:1884–1891.CrossRefPubMedGoogle Scholar
  30. 30.
    Pepine CJ, Handberg EM, Cooper-DeHoff RM, et al.: A calcium antagonist vs a non–calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial. JAMA 2003, 290:2805–2816.Google Scholar
  31. 31.
    Messerli F, Mancia G, Conti R, et al.: Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med 2006, 144:884–893.PubMedGoogle Scholar
  32. 32.
    Boutitie F, Gueyffier F, Pocock S, et al.: J-shaped relationship between blood pressure and mortality in hypertensive patients: new insights from a meta-analysis of individual-patient data. Ann Intern Med 2002, 136:438–448.PubMedGoogle Scholar
  33. 33.
    Ogihara T, Saruta T, Rakugi H, et al.: Relationship between the achieved blood pressure and the incidence of cardiovascular events in Japanese hypertensive patients with complications: a sub-analysis of the CASE-J trial. Hypertension Research 2009, 32:248–254.CrossRefPubMedGoogle Scholar
  34. 34.
    Protogerou A, Safar M, Iaria P, et al.: Diastolic blood pressure and mortality in the elderly with cardiovascular disease. Hypertension 2007, 50:172–180.CrossRefPubMedGoogle Scholar
  35. 35.
    Berl T, Hunsicker LG, Lewis JB, et al: Impact of achieved blood pressure on cardiovascular outcomes in the Irbesartan Diabetic Nephropathy Trial. J Am Soc Nephrol 2005, 16:2170–2179.CrossRefPubMedGoogle Scholar
  36. 36.
    Domanski M, Mitchell G, Pfeffer M, et al.: Pulse pressure and cardiovascular disease related mortality: follow-up study of the Multiple Risk factor Intervention Trial (MRFIT). JAMA 2002, 287:2677–2683.CrossRefPubMedGoogle Scholar
  37. 37.
    Bulpitt CJ, Palmer AJ, Fletcher AE, et al.: Optimal blood pressure control in treated hypertensive patients. Report from the Department of Health Hypertension Care Computing Project (DHCCP). Circulation 1994, 90:225–233.PubMedGoogle Scholar
  38. 38.
    Bloch MJ, Basile JN: Analysis of recent papers in hypertension. J Clin Hypertens (Greenwich) 2009, 11:292–295.CrossRefGoogle Scholar
  39. 39.
    Tuomilehto J, Ryynänen OP, Koistinen A, et al.: Low diastolic blood pressure and mortality in a population-based cohort of 16 913 hypertensive patients in North Karelia, Finland. J Hypertens 1998, 16:1235–1242.CrossRefPubMedGoogle Scholar
  40. 40.
    •• Cushman WC, Grimm RH Jr, Cutler JA, et al.: Rationale and design for the blood pressure intervention of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Am J Cardiol 2007, 99:44i–55i. The BP arm of the ACCORD trial is testing the hypothesis that aggressive treatment of hypertension in type 2 diabetes by lowering BP to lower targets will improve outcomes.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Monisankar Roy
    • 1
  • Noman Mahmood
    • 1
  • Clive Rosendorff
    • 1
  1. 1.Mount Sinai School of MedicineJames J. Peters VA Medical CenterBronxUSA

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