Treatment of Hypertension in Patients with Coronary Artery Disease

Hypertension is among the leading causes of mortality worldwide, both in the developed and developing world. Most deaths occur due to cardiovascular complications such as myocardial infarction (MI) and stroke. In the Asia Pacific Region, hypertension alone contributes to 66% of all cardiovascular deaths, more than it does worldwide. The most recent meta-analysis on the benefits of treating hypertension showed that tighter control of blood pressure (133/76 mmHg) leads to a significant 14% reduction in myocardial infraction. In patients with concurrent Coronary Artery Disease (CAD) the two issues which need to be addressed are: 1) to determine the target of blood pressure (BP), and; 2) to determine the drug of choice in hypertensive patients with concurrent CAD. Up to five years ago, most Clinical Practice Guidelines suggested that target BP to be achieved was <130/80 mmHg. This however was revised recently to <140/90 mmHg. The new cut-off was mainly due to lack of evidence from randomized controlled trials on the lower BP of <130/80 mmHg and the persistence concern about the J curve. This article reviewed recommendations made by the latest Hypertension Guidelines across major hypertension societies in North America, Europe and the Asia Pacific Region published over the last 3 years in the English language. These were than compared with major clinical outcome studies investigating phenotype of patients with hypertension and CAD. The treatment of choice for patients with CAD depends on clinical circumstances. In patients with underlying CAD, calcium channel blockers (verapamil) and beta blockers (atenolol) are indicated based on the INVEST trial. Besides, ACE I should also be the treatment of choice as indicated by the EUROPA trial especially in patients with minimal symptomatic angina. Beta blockers and dihydropyridine calcium channel blockers are indicated for symptomatic angina although there is no evidence of their impact on prognosis. For patients with previous myocardial infarction and normal left ventricular ejection fraction , ACE I and beta blockers are the drugs of choice to improve prognosis and clinical outcome although doubt has been raised on the benefits of beta blockers especially for mortality reduction. As for post-MI patients with reduced left ventricular ejection fraction, ACE I (or ARB), beta blockers and aldosterone antagonist are indicated.