Abstract
Hypertension is present in three of four patients with coronary artery disease (CAD) but remains largely uncontrolled in most patients. Treating hypertension in these patients is complicated by the concern of precipitating coronary ischemia when diastolic blood pressure (DBP) is reduced excessively. However, an emerging body of evidence from recent clinical trials in high-risk hypertensive patients with or without CAD demonstrated the benefit of intensive drug therapy, even when DBP fell much lower than 80 mm Hg, in terms of reducing cardiovascular events and progression of coronary and carotid atherosclerosis. Accordingly, the American Heart Association has now set the target BP goal to less than 130/80 mm Hg in hypertensive patients with CAD. Given the enormous gap between current BP levels in patients with CAD and the new target BP goals, multiple drug therapy is essential to achieve BP control and improve cardiovascular outcomes.
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Wong ND, Lopez VA, L’Italien G, et al.: Inadequate control of hypertension in US adults with cardiovascular disease comorbidities in 2003–2004. Arch Intern Med 2007, 167:2431–2436.
Wong ND, Lopez V, Tang S, Williams GR: Prevalence, treatment, and control of combined hypertension and hypercholesterolemia in the United States. Am J Cardiol 2006, 98:204–208.
Cheng S, Lichtman JH, Amatruda JM, et al.: Knowledge of blood pressure levels and targets in patients with coronary artery disease in the USA. J Hum Hypertens 2005, 19:769–774.
Thune JJ, Signorovitch J, Kober L, et al.: Effect of antecedent hypertension and follow-up blood pressure on outcomes after high-risk myocardial infarction. Hypertension 2008, 51:48–54.
Pepine CJ, Kowey PR, Kupfer S, et al.: Predictors of adverse outcome among patients with hypertension and coronary artery disease. J Am Coll Cardiol 2006, 47:547–551.
Coca A, Messerli FH, Benetos A, et al.: Predicting stroke risk in hypertensive patients with coronary artery disease: a report from the INVEST. Stroke 2008, 39:343–348.
Mancia G, Messerli F, Bakris G, et al.: Blood pressure control and improved cardiovascular outcomes in the International Verapamil SR-Trandolapril Study. Hypertension 2007, 50:299–305.
Ford ES, Ajani UA, Croft JB, et al.: Explaining the decrease in U.S. deaths from coronary disease, 1980–2000. N Engl J Med 2007, 356:2388–2398.
Polese A, De Cesare N, Montorsi P, et al.: Upward shift of the lower range of coronary flow autoregulation in hypertensive patients with hypertrophy of the left ventricle. Circulation 1991, 83:845–853.
Tamborini G, Maltagliati A, Trupiano L, et al.: Lowering of blood pressure and coronary blood flow in isolated systolic hypertension. Coron Artery Dis 2001, 12:259–265.
Neglia D, Gallopin M, Marraccini P, et al.: Effects of intravenous amlodipine on coronary hemodynamics in subjects with angiographically normal coronary arteries. J Cardiovasc Pharmacol 2002, 39:884–891.
Ishibashi Y, Shimada T, Nosaka S, et al.: Effects of heart rate on coronary circulation and external mechanical efficiency in elderly hypertensive patients with left ventricular hypertrophy. Clin Cardiol 1996, 19:620–630.
Gandhi SK, Powers JC, Nomeir AM, et al.: The pathogenesis of acute pulmonary edema associated with hypertension. N Engl J Med 2001, 344:17–22.
Fagard RH, Staessen JA, Thijs L, et al.: On-treatment diastolic blood pressure and prognosis in systolic hypertension. Arch Intern Med 2007, 167:1884–1891.
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.
Protogerou AD, Safar ME, Iaria P, et al.: Diastolic blood pressure and mortality in the elderly with cardiovascular disease. Hypertension 2007, 50:172–180.
Glynn RJ, L’Italien GJ, Sesso HD, et al.: Development of predictive models for long-term cardiovascular risk associated with systolic and diastolic blood pressure. Hypertension 2002, 39:105–110.
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.
Wang JG, Staessen JA, Franklin SS, et al.: Systolic and diastolic blood pressure lowering as determinants of cardiovascular outcome. Hypertension 2005, 45:907–913.
Hasebe N, Kido S, Ido A, Kenjiro K: Reverse J-curve relation between diastolic blood pressure and severity of coronary artery lesion in hypertensive patients with angina pectoris. Hypertens Res 2002, 25:381–387.
Franklin SS, Larson MG, Khan SA, et al.: Does the relation of blood pressure to coronary heart disease risk change with aging? The Framingham Heart Study. Circulation 2001, 103:1245–1249.
Lewington S, Clarke R, Qizilbash N, et al.: 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.
Messerli FH, Mancia G, Conti CR, 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.
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.
Nissen SE, Tuzcu EM, Libby P, et al.: Effect of antihypertensive agents on cardiovascular events in patients with coronary disease and normal blood pressure: the CAMELOT study: a randomized controlled trial. JAMA 2004, 292:2217–2225.
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.
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.
Chen ZM, Pan HC, Chen YP, et al.: Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet 2005, 366:1622–1632.
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.
Avanzini F, Ferrario G, Santoro L, et al.: Risks and benefits of early treatment of acute myocardial infarction with an angiotensin-converting enzyme inhibitor in patients with a history of arterial hypertension: analysis of the GISSI-3 database. Am Heart J 2002, 144:1018–1025.
Jamerson KA, Basile J: Prompt, aggressive BP lowering in high-risk patients. J Clin Hypertens (Greenwich) 2008, 10:40–48.
Verdecchia P, Reboldi G, Angeli F, et al.: Angiotensin-converting enzyme inhibitors and calcium channel blockers for coronary heart disease and stroke prevention. Hypertension 2005, 46:386–392.
Pfeffer MA, McMurray JJ, Velazquez EJ, et al.: Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med 2003, 349:1893–1906.
Doulton TW, He FJ, MacGregor GA: Systematic review of combined angiotensin-converting enzyme inhibition and angiotensin receptor blockade in hypertension. Hypertension 2005, 45:880–886.
McMurray JJ, Ostergren J, Swedberg K, et al.: Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting-enzyme inhibitors: the CHARM-Added trial. Lancet 2003, 362:767–771.
Pitt B, Remme W, Zannad F, et al.: Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003, 348:1309–1321.
Sharabi Y, Adler E, Shamis A, et al.: Efficacy of add-on aldosterone receptor blocker in uncontrolled hypertension. Am J Hypertens 2006, 19:750–755.
Mahmud A, Mahgoub M, Hall M, Feely J: Does aldosterone-to-renin ratio predict the antihypertensive effect of the aldosterone antagonist spironolactone? Am J Hypertens 2005, 18:1631–1635.
Elliott WJ, Meyer PM: Incident diabetes in clinical trials of antihypertensive drugs: a network meta-analysis. Lancet 2007, 369:201–207.
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Vongpatanasin, W. Management of hypertension in patients with coronary artery disease. Current Science Inc 10, 349–354 (2008). https://doi.org/10.1007/s11906-008-0066-2
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DOI: https://doi.org/10.1007/s11906-008-0066-2