The risk for the primary outcome, all-cause death, and MI, but not stroke, progressively increased with low diastolic blood pressure. Excessive reduction in diastolic pressure should be avoided in patients with CAD who are being treated for hypertension.

No abstract

Among CAD patients with hypertension, RHR predicts adverse outcomes, and on-treatment RHR is more predictive than baseline RHR. A Ve strategy is less effective than an At strategy for lowering RHR but has a similar effect on adverse outcomes.

Abstract-Uncontrolled blood pressure (BP) increases cardiovascular risk, independent of type of treatment. In this posthoc International Verapamil SR-Trandolapril Study analysis, we determined whether adverse outcomes are related to consistency of BP control, defined as the proportion of visits in which BP was in control. A total of 22 576 patients with hypertension and coronary artery disease were divided into 4 groups according to the proportion of visits in which BP was in control (Ͻ140/90 mm Hg): Ͻ25%, 25% to Ͻ50%, 50% to Ͻ75%, and Ն75%. Risk of primary outcome (first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke), myocardial infarction, and stroke decreased progressively from the group with Ͻ25% to the group with Ն75% of visits with BP control. Adjusted risks of primary outcome (heart rate: 0.60; 95% CI: 0.53 to 0.67), myocardial infarction (heart rate: 0.58; 95% CI: 0.48 to 0.70), and stroke (heart rate: 0.50; 95% CI: 0.37 to 0.67) were less in the group with Ն75% of visits with BP control compared with the group with Ͻ25% of visits with BP control. Baseline BP was not predictive of outcomes. Proportion of visits with BP control was associated with mean follow-up systolic BP (r 2 ϭ0.64), both being independently related to primary outcome. As proportion of visits with BP control increases, there is an associated steep reduction in cardiovascular risk, independent of baseline characteristics and mean on-treatment BP. Consistency of BP control during treatment provides additional information on the protective effect of antihypertensive treatment. Physicians need to be concerned at each visit if BP is not controlled. S everal lines of evidence support the view that blood pressure (BP) lowering, per se protects hypertensive patients, no matter how it is obtained. First, regardless of the treatment used, cardiovascular morbid and fatal events are less in patients in whom on-treatment BP is reduced Ͻ140/ 90 mm Hg than in those in whom on-treatment BP remains uncontrolled. 1-4 Second, regardless of the treatment used, in diabetic or other high-risk individuals, cardiovascular protection is greater if on-treatment BP values Ͻ130/80 mm Hg are achieved. 5-9 Third, there is a type of treatment-independent relationship between the magnitude of the mean BP change throughout the treatment period and the incidence of cerebrovascular and coronary events. 10,11 Analysis of BP control using mean follow-up BP does not provide a complete picture of BP control during a study, because BP may be in control at one visit and not in control at the next visit or vice versa. In the ELSA Study, for example, the number of patients with BP control at any given annual visit was much greater than the number of patients with consistent BP control at all 4 of the annual visits. 12 The purpose of this posthoc analysis of the large database provided by the INternational VErapamil SR-Trandolapril (INVEST) prospective trial was to determine whether study outcomes are related to the consistency of BP control, defined as...

BACKGROUND-Our understanding of the growing population of very old patients (aged ≥80 years) with coronary artery disease and hypertension is limited, particularly the relationship between blood pressure and adverse outcomes.

In CAD patients with hypertension, PP (on anti-hypertensive treatment) is a weaker predictor of cardiovascular outcomes than SBP, DBP, or MAP.

SummaryThe INternational VErapamil SR-Trandolapril STudy (INVEST), a randomized trial of 22,576 predominantly elderly patients with an average 2.7-year follow-up, compared a calcium antagonist led strategy (verapamil SR plus trandolapril) with a β blocker led strategy (atenolol plus hydrochlorothiazide) for hypertension treatment and prevention of cardiovascular outcomes in coronary artery disease. patients.Patients received individualized dose and drug titration following a flexible, multi-drug, guidelinebased treatment algorithm, with the objective of achieving optimal blood pressure (BP) control individualized for comorbidities (e.g., diabetes). The primary outcome (PO) was first occurrence of death (all-cause), nonfatal myocardial infarction or nonfatal stroke.The strategies resulted in significant and very similar BP reduction with approximately 70% of patients in both strategies achieving BP control (< 140/90 mm Hg). Increasing number of office visits with BP in control was associated with reduced risk of the PO. Overall, there was no difference in the PO comparing the strategies, however new onset diabetes occurred more frequently in those assigned the atenolol strategy. This report summarizes findings from INVEST and puts them in perspective with our current state of knowledge derived from other large hypertension treatment trials. INVEST findings support that 1) BP reduction is important for prevention of adverse cardiovascular morbidity and mortality; and 2) selection of antihypertensive agents should be based on patient comorbidities and other risk factors (e.g. risk for diabetes) and not necessarily that any one drug be given to all.

Metabolic syndrome (MS), typified by hypertension, abdominal obesity, dyslipidaemia and impaired glucose metabolism, is a precursor of type 2 diabetes. Thiazide diuretics (TD) and beta-blockers are associated with increased risk of diabetes in patients with hypertension; however, the role of these agents in development of diabetes in MS patients is unknown. We reviewed the literature regarding risk factors for diabetes development and compared this with data from the Study of Trandolapril/Verapamil SR And Insulin Resistance (STAR), which investigated the effects of two fixed-dose combinations (FDCs) [trandolapril/verapamil SR and losartan/hydrochlorothiazide (L/H)] on glucose control and new diabetes in MS patients. In STAR, logistic regression modelling identified haemoglobin A1c [odds ratio (OR) 4.21 per 1% increment; p = 0.003), L/H treatment (OR 4.04; p = 0.002) and 2-h oral glucose tolerance test glucose levels (OR 1.39 per 10 mg/dl increments; p < 0.001) as baseline predictors of diabetes. These data support prior analyses and suggest that choice of antihypertensive agent is important. Patients with MS may be at lower risk of diabetes when using a FDC calcium channel blocker + angiotensin-converting enzyme inhibitor compared with an angiotensin receptor blocker + TD.