European Heart Journal Advance Access originally published online on October 23, 2006
European Heart Journal 2006 27(23):2903; doi:10.1093/eurheartj/ehl309
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Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology: reply
Royal Brompton Hospital
Sydney Street
London SW3 6NP
UK
E-mail address: c.daly{at}rbh.nthames.nhs.uk
Dept. of Public Health
University Hospital Ghent
De Pintelaan 185
9000 Ghent
Belgium
Royal Brompton Hospital
Sydney Street
London SW3 6NP
UK
We thank the authors for raising the interesting discussion regarding the treatment of hypertension in patients with concomitant coronary disease. The J-shaped association between on-treatment blood pressure and risk has been described in longitudinal cohorts of patients with treated hypertension as well as in clinical trial populations, both in on-treatment and control arms. However, it is not absolutely clear that the association is treatment-related; in fact, one meta-analysis of seven randomized controlled trials including data on more than 40 000 patients has shown that the J-shaped relationship between blood pressure and mortality was not related to antihypertensive treatment.1 In this meta-analysis, non-cardiovascular death was inversely related to blood pressure (both systolic and diastolic) in contrast to the J-shaped relationships for cardiovascular and total mortality, leading the authors to hypothesize that poor health conditions leading to low blood pressure and an increased risk of death might in part explain the J-shaped curve.
Secondly, as discussed in the full-text version of the guidelines, there is accumulating evidence that blood pressure lowering in the ‘normal’ range is associated with improved cardiovascular outcomes in the population with known coronary disease. In the CAMELOT study, patients with coronary disease and mean blood pressure of 129/78 were randomized to enalapril, amlodipine, or placebo.2 Blood pressure reductions were similar (5/2 mm) in both treatment groups and associated with similar relative reductions in the composite endpoint of cardiovascular death, MI, and stroke, although not statistically significant in either group because of the small sample size. An intravascular ultrasound substudy demonstrated a significant inverse correlation between progression of atherosclerosis and blood pressure reduction even in this normal blood pressure range, with the greatest benefit observed in patients whose blood pressure fell below 120/80.3
Thus, the task force has felt it important, in the absence of unequivocal evidence to the contrary, to preserve consistency between guidelines on prevention and angina with regard to targets for institution of therapy for hypertension in the presence of coronary disease. No lower limit has yet been identified as a definite cutoff beyond which blood pressure should not be lowered further, although, clearly, symptomatic hypotension or postural hypotension will limit aggressive blood pressure lowering in the lower range.
References
- Boutitie F, Gueyffier F, Pocock S, Fagard R, Boisel JP. (2002) J-shaped relationship between blood pressure and mortality in hypertensive patients: new insights from a meta-analysis of individual—patient data. Ann Intern Med 136:438–448.
[Abstract/Free Full Text] - Nissen SE, Tuzcu EM, Libby P, Thompson PD, Ghali M, Garza D, Berman L, Shi H, Buebendorf E, Topol EJ. CAMELOT Investigators. (2004) Effect of antihypertensive agents on cardiovascular events in patients with coronary disease and normal blood pressure: the CAMELOT study: a randomized controlled trial. JAMA 292:2217–2225.
[Abstract/Free Full Text] - Sipahi I, Tuzcu EM, Schoenhagen P, Wolski KE, Nicholls SJ, Balog C, Crowe TD, Nissen SE. (2006) Effects of normal, pre-hypertensive, and hypertensive blood pressure levels on progression of coronary atherosclerosis. JACC 48:833–838.
[Abstract/Free Full Text]
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