New recommendations support lower BP target to reduce risk for MI, stroke
Patients with hypertension and CAD should be treated to a BP goal of less than 140 mm Hg systolic/90 mm Hg diastolic, according to a scientific statement from the American Heart Association, American College of Cardiology and American Society of Hypertension.
While a target of < 140 mm Hg/90 mm Hg is reasonable to prevent MI and stroke in this patient population, a target of < 130 mm Hg/80 mm Hg may be appropriate in some people with CVD who have had a MI, stroke or transient ischemic attack, or risk equivalents such as peripheral artery disease and abdominal aortic aneurysm, writing committee chair Clive Rosendorff, MD, PhD, DScMed, FAHA, FACC, FASH, and colleagues wrote.
“This is important since confusion has arisen in the clinical community over the last year regarding the appropriate target for [BP] management in the general population,” Elliott Antman, MD, AHA president and professor of medicine at Harvard Medical School, said in a press release.
Advice on BP lowering
The statement covers the association between hypertension and CAD; prevention of CV events in patients with hypertension and CAD; BP goals; management of hypertension in patients with CAD and stable angina; management of hypertension in patients with ACS; and management of hypertension in patients with HF of ischemic origin.
According to the authors, BP lowering can usually be done safely with standard medications in this population. However, they wrote, in patients with elevated diastolic BP and CAD with evidence of myocardial ischemia, BP should be lowered slowly, and diastolic BP should not usually be decreased to < 60 mm Hg in patients who are aged older than 60 years or have diabetes.
Patients with hypertension and chronic stable angina should be treated with a regimen including a beta-blocker in patients with a prior MI; an ACE inhibitor or angiotensin receptor blocker in patients with a prior MI, left ventricular systolic dysfunction, diabetes or chronic kidney disease; and a thiazide or thiazide-like diuretic, according to the statement.
In patients with ACS and hypertension, recommended initial therapy for hypertension includes a short-acting beta-blocker such as metoprolol or bisoprolol and an IV beta-blocker such as esmolol for those with severe hypertension or ongoing ischemia, according to the statement. Nitrates are also appropriate for most patients in this group, and an ACE inhibitor should be added if the patient has anterior MI, LV dysfunction, HF, diabetes or persistent hypertension.
Patients with HF with reduced ejection fraction and hypertension are recommended to receive ACE inhibitors or angiotensin receptor blockers, beta-blockers and aldosterone receptor antagonists. Thiazide and thiazide-type diuretics are recommended for BP control and to reverse volume overload, but spironolactone or eplerenone may be substituted in patients needing a potassium-sparing agent.
Patients with HF with preserved EF and hypertension may benefit from beta-adrenergic blocking agents, ACE inhibitors, angiotensin receptor blockers or calcium channel blockers, according to the statement.
“In the spectrum of drugs available for the treatment of hypertension, beta-blockers assume center stage in patients with [CAD],” Rosendorff, professor of medicine at the Icahn School of Medicine at Mount Sinai and director of graduate medical education at the Veterans Administration in Bronx, New York, said in the release. Rosendorff also noted that these therapies can slow heart rate, reduce the force of cardiac contraction and increase blood flow to the heart.
“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,” he said. – by Erik Swain
Disclosure: Rosendorff reports no relevant financial disclosures.