The 2015 American Heart Association/American College of Cardiology/American Society of Hypertension Scientific Statement “Treatment of Hypertension in Patients with Coronary Artery Disease” is summarized in the context of a clinical case. The Statement deals with target blood pressures, and the optimal agents for the treatment of hypertension in patients with stable angina, in acute coronary syndromes, and in patients with ischemic heart failure. In all cases, the recommended blood pressure target is <140/90 mm Hg, but <130/80 mm Hg may be appropriate, especially in those with a history of a previous myocardial infarction or stroke, or at high risk for developing either. These numbers may need to be revised after the publication of the SPRINT data. Appropriate management should include beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and in the case of heart failure, aldosterone antagonists. Thiazide or thiazide-like (chlorthalidone) diuretics and calcium channel blockers can be used for the management of hypertension, but the evidence for improved outcomes compared with other agents in hypertension with coronary artery disease is meager. Loop diuretics should be reserved for patients with New York Heart Association Class III and IV heart failure or with a glomerular filtration rate of <30 mL/min.
July 2015 saw the publication of the Scientific Statement “Treatment of Hypertension in Patients with Coronary Artery Disease,” sponsored by the American Heart Association, the American College of Cardiology, and the American Society of Hypertension. The motivation for the Statement was clear: there is a strong epidemiologic association between hypertension and coronary artery disease; they have many pathophysiologic features in common and there are unique management challenges in these patients.
The Oslerian epigraph above provides a cue to structure this summary of the clinical sections of the Statement around a real patient.
Blood Pressure Targets
A 62-year-old man has hypertension and coronary artery disease. His hypertension is currently treated with lisinopril 20 mg per day and hydrochlorothiazide 25 mg per day. His blood pressure at his latest clinic visit is 138/88 mm Hg. He had a myocardial infarction 5 years previously.
What Is an Appropriate Blood Pressure Target for This Patient?
A major section of the statement addresses blood pressure targets. The debate on this revolves around the issue of whether targets lower than the conventional <140/90 mm Hg are appropriate or even safe for patients with coronary artery disease. Because the diastolic blood pressure is the coronary perfusion pressure, the diastolic blood pressure is the critical value in this discussion.
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-Clive Rosendorff, MD, PhD
Other Hypertension Research in This Issue.
This article originally appeared in the April 2016 issue of The American Journal of Medicine.
