Relationships Between Components of Blood Pressure and Cardiovascular Events in Patients with Stable Coronary Artery Disease and Hypertension

Observational studies have shown a J-shaped relationship between diastolic blood pressure (BP) and cardiovascular events in hypertensive patients with coronary artery disease. We investigated whether the increased risk associated with low diastolic BP reflects elevated pulse pressure (PP). In 22 672 hypertensive patients with coronary artery disease from the CLARIFY registry (Prospective Observational Longitudinal Registry of Patients With Stable Coronary Artery Disease), followed for a median of 5.0 years, BP was measured annually and averaged. The relationships between PP and diastolic BP, alone or combined, and the primary composite outcome (cardiovascular death or myocardial infarction) were analyzed using multivariable Cox proportional hazards models. Adjusted hazard ratios for the primary outcome were 1.62 (95% confidence interval [CI], 1.40–1.87), 1.00 (ref), 1.07 (95% CI, 0.94–1.21), 1.54 (95% CI, 1.32–1.79), and 2.34 (95% CI, 1.95–2.81) for PP<45, 45 to 54 (reference), 55 to 64, 65 to 74, and ≥75 mm Hg, respectively, and 1.50 (95% CI, 1.31–1.72), 1.00 (reference), and 1.58 (95% CI, 1.42–1.77) for diastolic BPs of <70, 70 to 79 (ref), and ≥80 mm Hg, respectively. In a cross-classification analysis between diastolic BP and PP, the relationship between diastolic BP and the primary outcome remained J-shaped when the analysis was restricted to patients with the lowest-risk PP (45–64 mm Hg), with adjusted hazard ratios of 1.53 (95% CI, 1.27–1.83), 1.00 (ref), and 1.54 (95% CI, 1.34–1.75) in the <70, 70 to 79 (reference), and ≥80 mm Hg subgroups, respectively. The J-shaped relationship between diastolic BP and cardiovascular events in hypertensive patients with coronary artery disease persists in patients within the lowest-risk PP range and is therefore unlikely to be solely the consequence of an increased PP reflecting advanced vascular disease. Clinical Trial Registration— URL: http://www.clarify-registry.com. Unique identifier: ISRCTN43070564.

[1]  P. Whelton,et al.  Systolic Blood Pressure Reduction and Risk of Cardiovascular Disease and Mortality: A Systematic Review and Network Meta-analysis , 2017, JAMA cardiology.

[2]  S. Bangalore,et al.  Optimal Systolic Blood Pressure Target After SPRINT: Insights from a Network Meta-Analysis of Randomized Trials. , 2017, The American journal of medicine.

[3]  R. Ravindrarajah,et al.  Systolic Blood Pressure Trajectory, Frailty, and All-Cause Mortality >80 Years of Age: Cohort Study Using Electronic Health Records , 2017, Circulation.

[4]  Deepak L. Bhatt,et al.  Cardiovascular event rates and mortality according to achieved systolic and diastolic blood pressure in patients with stable coronary artery disease: an international cohort study , 2016, The Lancet.

[5]  Deepak L. Bhatt Troponin and the J-Curve of Diastolic Blood Pressure: When Lower Is Not Better. , 2016, Journal of the American College of Cardiology.

[6]  J. Coresh,et al.  60 A comparison of HFrEF vs HFpEF’s clinical workload and cost in the first year following hospitalisation and enrollment in a disease management program , 2016, Journal of the American College of Cardiology.

[7]  D. Wood,et al.  The Impact of Left Ventricular Mass on Diastolic Blood Pressure Targets for Patients With Coronary Artery Disease. , 2016, American journal of hypertension.

[8]  G. Mancia,et al.  Unattended Blood Pressure Measurements in the Systolic Blood Pressure Intervention Trial: Implications for Entry and Achieved Blood Pressure Values Compared With Other Trials , 2016, Hypertension.

[9]  G. Mancia,et al.  Unobserved automated office blood pressure measurement in the Systolic Blood Pressure Intervention Trial (SPRINT): systolic blood pressure treatment target remains below 140 mmHg. , 2016, European heart journal. Cardiovascular pharmacotherapy.

[10]  S. Anderson,et al.  Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis , 2016, The Lancet.

[11]  Deepak L. Bhatt,et al.  Pulse Pressure and Risk for Cardiovascular Events in Patients With Atherothrombosis: From the REACH Registry. , 2016, Journal of the American College of Cardiology.

[12]  P. Meredith,et al.  Prognostic importance of pretreatment and on-treatment blood pressure: Further analysis of the ACTION database and the effect of nifedipine gastrointestinal therapeutic system , 2016, Blood pressure.

[13]  J. McMurray,et al.  Differing prognostic value of pulse pressure in patients with heart failure with reduced or preserved ejection fraction: results from the MAGGIC individual patient meta-analysis. , 2015, European heart journal.

[14]  D. Levy,et al.  Does Low Diastolic Blood Pressure Contribute to the Risk of Recurrent Hypertensive Cardiovascular Disease Events?: The Framingham Heart Study , 2015, Hypertension.

[15]  J. Tardif,et al.  Prevalence of anginal symptoms and myocardial ischemia and their effect on clinical outcomes in outpatients with stable coronary artery disease: data from the International Observational CLARIFY Registry. , 2014, JAMA internal medicine.

[16]  R. Conwit,et al.  Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial , 2013, The Lancet.

[17]  S. Bangalore,et al.  J-curve revisited: An analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) Trial. , 2010, European heart journal.

[18]  G. Mancia,et al.  Pulse pressure and risk of cardiovascular outcomes in patients with hypertension and coronary artery disease: an INternational VErapamil SR-trandolapril STudy (INVEST) analysis. , 2009, European heart journal.

[19]  D. Levy,et al.  Single Versus Combined Blood Pressure Components and Risk for Cardiovascular Disease: The Framingham Heart Study , 2009, Circulation.

[20]  J. Filipovský,et al.  Diastolic Blood Pressure and Mortality in the Elderly With Cardiovascular Disease , 2007, Hypertension.

[21]  Michael Böhm,et al.  2013 ESH/ESC Guidelines for the management of arterial hypertension , 2007, Blood pressure.

[22]  R. Vasan,et al.  Aggressive lowering of blood pressure , 2006, The Lancet.

[23]  G. Mancia,et al.  Dogma Disputed: Can Aggressively Lowering Blood Pressure in Hypertensive Patients with Coronary Artery Disease Be Dangerous? , 2006, Annals of Internal Medicine.

[24]  R. D'Agostino,et al.  A likely explanation for the J-curve of blood pressure cardiovascular risk. , 2004, The American journal of cardiology.

[25]  Anthony F. Lever,et al.  Implications of Pulse Pressure as a Predictor of Cardiac Risk in Patients With Hypertension , 2000, Hypertension.

[26]  R H Fagard,et al.  Pulse pressure not mean pressure determines cardiovascular risk in older hypertensive patients. , 1999, Archives of internal medicine.

[27]  C. Escobar Cervantes,et al.  [A randomized trial of intensive versus standard blood pressure control]. , 2016, Semergen.

[28]  Kevin A Peterson,et al.  Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus , 2011 .

[29]  W. Elliott The J-Curve Between Blood Pressure and Coronary Artery Disease or Essential Hypertension: Exactly How Essential? , 2010 .

[30]  M. Safar Relation of pulse pressure and blood pressure reduction to the incidence of myocardial infarction. , 1994, Hypertension.