Optimal medical treatment of hypertension in patients with coronary artery disease

ABSTRACT

Introduction: Coronary artery disease (CAD) remains the leading cause of mortality and morbidity worldwide, and hypertension is its most prevalent modifiable risk factor. Patients with CAD and concomitant hypertension are a special population with distinct physiologic and structural alterations. Optimal blood pressure (BP) control in this population has been linked with reduction in adverse outcomes, however, excessive lowering of BP could jeopardize myocardial and cerebral perfusion.

Areas covered: Authors highlight the prevalence of the CAD and hypertension dyad, as well as the implications of various structural and physiological changes in this population. Subsequently, available data on optimal BP targets in such patients, and lastly the J-curve phenomenon as well as antihypertensive agent use are discussed.

Expert commentary: Current guideline recommendations are based on data from trials such as SPRINT and ACCORD which did not specifically focus on the CAD population. Based on data from observational studies and post hoc analyses, the best therapeutic systolic (SBP) and diastolic (DBP) targets may be ~ 130 mmHg and ~ 80 mmHg, respectively. Caution should be taken to not lower SBP below 120 mmHg and DBP below 60 mmHg.

KEYWORDS:

• Antihypertensives
• coronary auto-regulation
• endothelial dysfunction
• J-curve phenomenon
• major adverse cardiovascular events
• pulse-wave velocity
• target blood pressure

Declaration of interest

CJ Pepine receives support from the Gatorade Trust through funds distributed by the University of Florida, Department of Medicine; NIH NCATS—University of Florida Clinical and Translational Science UL1TR001427; and PCORnet-OneFlorida Clinical Research Consortium CDRN-1501-26692. CJ Pepine also reports grant support (significant) from Adelphi Values (Qualitative MVA), Amorcyte (PRESERVE), Athersys (MI-NSTEMI), BioCardia (CardiAMP), Brigham and Women’s Hospital (INVESTED), Capricor (ALLSTAR), Cytori Therapeutics (ATHENA), Duke Univ. (ADAPTABLE), Gilead Sciences Inc. (RWISE, Univ. FL site), Merck & Co. Inc. (VICTORIA), Mesoblast (TEVA, Univ. FL site), NIH/NHLBI (CONCERT), US Dept. of Defense (WARRIOR), Ventrix (CV-201); educational support (modest) for the Vascular Biology Working Group from Amgen Inc., AstraZeneca Pharmaceuticals, Boehringer Ingelheim Pharmaceuticals Inc., Daiichi Sankyo, Ionis, Relypsa; Consultant fees/honoraria (modest) from Amgen Inc., AstraZeneca Pharmaceuticals, Bayer Healthcare Pharmaceuticals, Gilead, Merck and (significant) from Ironwood Pharmaceuticals Inc. and SLACK Inc.; is a Task force member (no compensation) for Foundation for the Accreditation of Cellular Therapy. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.