The new statement on treating hypertension in patients with established coronary artery disease clears up what had been a confusing situation for U.S. physicians during the past year.
In early 2014, the panel that had originally been assembled as the Eighth Joint National Committee (JNC 8) issued a statement that called for a blood pressure target of less than 150/90 mm Hg for people 60 years or older (JAMA 2014;311:507-20). People were very confused about that, and may have erroneously believed that this recommendation applied to patients with CAD. I and many of my colleagues believe that having a recommendation to treat to just less than 150/90 mm Hg potentially put millions of CAD patients at risk, especially at risk for stroke. The new statement highlights the high risk faced by CAD patients who need special attention to their blood pressure.
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| Mitchel L. Zoler/Fronbtline Medical News Dr. Elliott M. Antman |
The epidemiologic evidence clearly shows that increased blood pressure relates to an increased risk for cardiovascular events across a blood pressure range from 115/75 mm Hg to 185/115 mm Hg.
The new recommendations for CAD patients also say that a target blood pressure of less than 130/80 mm Hg may be preferred for selected patients, although the statement does not offer clear steps on how to identify these patients. Physicians must use their clinical judgment.
In my practice, I make sure not to drop a patient’s creatinine clearance to an unacceptably low level, and I would especially consider the lower target for patients with a history of heart failure or left ventricular dilatation or hypertrophy. I believe that in the past, physicians have been too conservative about blood pressure reduction in CAD patients, in part out of a concern about reducing perfusion pressure too much. I believe that if a CAD patient can tolerate a lower blood pressure and the treatment it takes to achieve it, then it is better to be more aggressive.
We also must always remember that the lifestyle modifications, including less dietary sodium, weight loss, and exercise, are the first steps to reducing blood pressure.
Dr. Elliott M. Antman is professor of medicine at Harvard University in Boston and president of the American Heart Association. He had no relevant disclosures. He made these comments in an interview.
