Health Care Providers in the Caribbean
Lower BP Targets for High-Risk and Established CAD Patients
New AHA Statement Sets Lower BP Targets for High-Risk and Established CAD Patients
Study Highlights
* For general prevention of ischemic heart disease, the BP should be lowered to less than 140/90 mm Hg. Among patients with a 10-year Framingham risk score for cardiovascular disease exceeding 10%, diabetes, CKD, or known CAD, the goal BP should be less than 130/80 mm Hg. The authors advocate a BP goal of less than 120/80 mm Hg among patients with left-sided ventricular dysfunction.
* Whereas the theory that an excessive drop in diastolic BP can promote worse cardiovascular outcomes is controversial and only partly supported by clinical studies, the authors recommend reducing the diastolic BP slowly. Caution is advised when the diastolic BP falls below 60 mm Hg among patients older than 60 years and those with diabetes.
* Reducing BP to goal levels is more important than the choice of antihypertensive drug in reducing cardiovascular risk. First-line therapy may include a thiazide diuretic, angiotensin-converting enzyme (ACE) inhibitor (or angiotensin receptor blocker [ARB]), or calcium channel blocker. If the BP goal requires a reduction of more than 20/10 mm Hg to reach goal, clinicians should consider using 2 medications to lower BP initiated simultaneously.
* Treatment for patients with hypertension and chronic stable angina should include a β-blocker if there is a history of prior myocardial infarction. Nondihydropyridine calcium channel blockers may be used if patients are intolerant of β-blockers but should not be used in the setting of left-sided ventricular dysfunction.
* β-Blockers are the treatment of choice for patients hospitalized with coronary syndromes. These patients should receive ACE inhibitors or ARBs if there is evidence of anterior myocardial infarction, persistent hypertension, or heart failure or if the patient has diabetes.
* Aldosterone antagonists may be considered for patients with left-sided ventricular dysfunction, but these medications should be avoided if the serum creatinine level meets or exceeds 2.5 mg/dL in men or 2.0 mg/dL in women. Aldosterone antagonists are also not appropriate for patients with serum potassium levels of 5 mEq/L or greater.
* Concomitant use of ACE inhibitors and ARBs should be avoided in the immediate period following ST-elevation myocardial infarction, but it is permissible to use medications from these different classes together among patients with hypertension and heart failure.
* α-Adrenergic antagonists such as doxazosin should be used among patients with hypertension and heart failure only when all other medications have been used to maximum effect.
Pearls for Practice
* Approximately one quarter of US adults have prehypertension and one quarter have hypertension, respectively. Systolic BP increases gradually as adults grow older, and it is a stronger predictor of ischemic heart disease than diastolic BP among adults older than 60 years.
* The current guidelines recommend that initial treatment of hypertension among patients without known heart disease or diabetes may include ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics.
Medscape Medical News 2007. ©2007 Medscape
Study Highlights
* For general prevention of ischemic heart disease, the BP should be lowered to less than 140/90 mm Hg. Among patients with a 10-year Framingham risk score for cardiovascular disease exceeding 10%, diabetes, CKD, or known CAD, the goal BP should be less than 130/80 mm Hg. The authors advocate a BP goal of less than 120/80 mm Hg among patients with left-sided ventricular dysfunction.
* Whereas the theory that an excessive drop in diastolic BP can promote worse cardiovascular outcomes is controversial and only partly supported by clinical studies, the authors recommend reducing the diastolic BP slowly. Caution is advised when the diastolic BP falls below 60 mm Hg among patients older than 60 years and those with diabetes.
* Reducing BP to goal levels is more important than the choice of antihypertensive drug in reducing cardiovascular risk. First-line therapy may include a thiazide diuretic, angiotensin-converting enzyme (ACE) inhibitor (or angiotensin receptor blocker [ARB]), or calcium channel blocker. If the BP goal requires a reduction of more than 20/10 mm Hg to reach goal, clinicians should consider using 2 medications to lower BP initiated simultaneously.
* Treatment for patients with hypertension and chronic stable angina should include a β-blocker if there is a history of prior myocardial infarction. Nondihydropyridine calcium channel blockers may be used if patients are intolerant of β-blockers but should not be used in the setting of left-sided ventricular dysfunction.
* β-Blockers are the treatment of choice for patients hospitalized with coronary syndromes. These patients should receive ACE inhibitors or ARBs if there is evidence of anterior myocardial infarction, persistent hypertension, or heart failure or if the patient has diabetes.
* Aldosterone antagonists may be considered for patients with left-sided ventricular dysfunction, but these medications should be avoided if the serum creatinine level meets or exceeds 2.5 mg/dL in men or 2.0 mg/dL in women. Aldosterone antagonists are also not appropriate for patients with serum potassium levels of 5 mEq/L or greater.
* Concomitant use of ACE inhibitors and ARBs should be avoided in the immediate period following ST-elevation myocardial infarction, but it is permissible to use medications from these different classes together among patients with hypertension and heart failure.
* α-Adrenergic antagonists such as doxazosin should be used among patients with hypertension and heart failure only when all other medications have been used to maximum effect.
Pearls for Practice
* Approximately one quarter of US adults have prehypertension and one quarter have hypertension, respectively. Systolic BP increases gradually as adults grow older, and it is a stronger predictor of ischemic heart disease than diastolic BP among adults older than 60 years.
* The current guidelines recommend that initial treatment of hypertension among patients without known heart disease or diabetes may include ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics.
Medscape Medical News 2007. ©2007 Medscape
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