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New Recommendations for Treating Patients With Hypertension and Heart Disease
A new scientific statement issued jointly by three medical organizations and published in Hypertension addresses how low to aim when treating patients with hypertension who also have vascular diseases.
The document provides an up-to-date summary on treating hypertension in patients who have had a stroke, heart attack, or some other forms of heart disease, said Elliott Antman, MD, President of the American Heart Association (AHA) and professor of medicine at Harvard Medical School.
“The writing committee reinforces the target of less than 140/90 to prevent heart attacks and strokes in patients with hypertension and coronary artery disease [CAD],” he said. “This is important since confusion has arisen in the clinical community over the last year regarding the appropriate target for blood pressure [BP] management in the general population.”
The current statement was issued jointly by the AHA, the American College of Cardiology (ACA), and the American Society of Hypertension. The writing committee consisted of internationally recognized experts in the fields of cardiology and hypertension research.
According to the statement, while a target of less than 140/90 mm Hg is reasonable to avoid heart attacks and strokes, a lower target of less than 130/80 mm Hg may be appropriate in some individuals with heart disease who have already experienced a stroke, heart attack, or transient ischemic attack (“mini-stroke”) or who have other cardiovascular conditions, such as narrowing of leg arteries or abdominal aortic aneurysm.
BP lowering can be done safely, and the majority of individuals will not experience problems when standard medications are used, the committee writes. However, the statement recommends that clinicians use caution in patients with coronary artery blockages, advising that BP should be lowered slowly, and not strive to decrease the diastolic BP to less than 60 mm Hg, particularly in patients more than 60 years old.
According to the ACA, the following are ten points to remember about the new scientific statement:
- 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% to 60% lower risk of stroke death and a 40% to 50% lower risk of death resulting from CAD.
- 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.
- The BP target of less than 140/90 mm Hg is reasonable for the secondary prevention of cardiovascular disease in patients with hypertension and CAD. A lower target BP of less than 130/80 mm Hg may be appropriate in some individuals with CAD or in 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).
- A BP goal of less than 150/90 mm Hg is recommended in those who are 80 years of age or older. The writers of the scientific statement have suggested a target of less than 140/90 mm Hg for patients aged 65 to 79 years.
- 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 of less than 60 mm Hg should be made with caution in any patient with diabetes mellitus or who is older than 60 years of age.
- While there has been considerable controversy regarding the appropriateness of beta-blockers as first-line therapy in hypertension, there is convincing evidence for the use of beta-blockade in patients with angina, prior MI, or heart failure with a reduced ejection fraction.
- Patients with hypertension and chronic stable angina should be treated with a regimen that includes the following: a beta-blocker in those with a history of MI; an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin-receptor blocker (ARB) if there is prior MI, left ventricular systolic dysfunction, diabetes mellitus, or chronic kidney disease; and a thiazide or thiazide-like diuretic.
- In patients with acute coronary syndrome, a short-acting beta-1-selective beta-blocker without intrinsic sympathomimetic activity (e.g., metoprolol tartrate or bisoprolol) should be the initial therapy of hypertension and should be initiated orally within 24 hours of presentation, provided there are no contraindications.
- The following drugs should be avoided in patients with hypertension and heart failure with a 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.