TREATMENT OF HYPERTENSION IN THE PREVENTION AND MANAGEMENT OF ISCHEMIC HEART DISEASE

JOURNAL READING C O A S S I N T E R N A S TA S E CARDIOLOGY FK UNHALU

Epidemiological studies have established a strong association between hypertension and coronary artery disease (CAD). Hypertension is a major independent risk factor for the development of CAD, stroke, and renal failure

and Treatment of High Blood Pressure recommendations has defined “hypertension” as a BP of 140/90 mm Hg.Hypertension is a major independent risk factor for CAD. . Evaluation. defined as an SBP of 120 to 139 mm Hg or a DBP of 80 to 89 mm Hg. Another one fourth of the population is in the “prehypertension” range. Detection. The latest version of the Joint National Committee on Prevention. and renal failure. stroke.

MECHANISMS OF HYPERTENSION IN CAD • Physical Forces and Hemodynamics • Systolic Hypertension • Humoral and Metabolic Factors • Oxidative Stress .

↓ coronary flow reserve ↑ intramyocard wall tension LVH Complex function of the plaque occlusiv CAD Remodeling small n medium coronary arteries .HYPERTENSION AND CAD (HEMODINAMIC) In HT. ↓CBF. ↑ myocard O2 demand.

. CAD risk equivalents. abdominal aortic aneurysm. defined as those with a 10-year Framingham risk score of >10% (see Appendix). chronic renal disease. or abnormal carotid ultrasound or angiography). aggressive BP lowering is appropriate. carotid artery disease (carotid bruit. Level of Evidence B). peripheral arterial disease. and a target BP of <140/90 mm Hg in individuals with none of the above (Class IIa. with a target BP of <130/80 mm Hg in individuals with any of the following: diabetes mellitus. CAD. and for high-risk patients.RECOMMENDATION FOR PRIMARY PREVENTION OF CAD IN HYPERTENSION (1) For the primary prevention of CAD in hypertension.

especially those due to myocardial ischemia.(2) In patients with an elevated DBP and CAD with evidence of myocardial ischemia. the BP should be lowered slowly. . In the very old. but evidence for a reduction in coronary events is less certain (Class IIa. antihypertensive therapy is effective in reducing stroke risk. those over 80 years of age. In older hypertensive individuals with wide pulse pressures. lowering SBP may cause very low DBP values (<60 mm Hg). and caution is advised in inducing falls of DBP below 60 mm Hg if the patient has diabetes mellitus or is over the age of 60 years. Level of Evidence C). This should alert the clinician to assess carefully any untoward signs or symptoms.

(3) The choice of drugs remains controversial. rather than the choice of antihypertensive drug. supplemented by a second drug if BP control is not achieved by monotherapy. however. there is sufficient evidence in the comparative clinical trials to support the use of an ACE inhibitor (or ARB). is the major determinant of reduction of cardiovascular risk. . There is a general consensus that the amount of BP reduction. CCB. or thiazide diuretic as first-line therapy.

In the asymptomatic post-MI patient. Level of Evidence A). . and when the BP is >20/ 10 mm Hg above goal. 2 drugs should usually be used from the outset. (3) Most patients will require 2 or more drugs to reach goal. . a-blocker is a more appropriate choice for secondary prevention for at least 6 months after the infarction and is the drug of first choice if the patient has angina pectoris. This is discussed further in the next section (Class I.CONT.

Level of Evidence A).RECOMMENDATION FOR MANAGEMENT OF HYPERTENSION IN PATIENTS WITH CAD AND STABLE ANGINA (1) Patients with hypertension and chronic stable angina should be treated with a regimen that includes a B-blocker in patients with a history of prior MI. and a thiazide diuretic should also be considered in the absence of a prior MI. and a thiazide diuretic (Class I. an ACE inhibitor or ARB if there is diabetes mellitus and/or LV systolic dysfunction. ACE inhibitor or ARB. diabetes mellitus. or LV systolic dysfunction (Class IIa. Level of Evidence B) . The combination of a B-blocker.

(2) If -blockers are contraindicated or produce intolerable side effects. a nondihydropyridine CCB (such as diltiazem or verapamil) can be substituted. but not if there is LV dysfunction (Class IIa. Level of Evidence B). . a long-acting dihydropyridine CCB can be added to the basic regimen of -blocker. (3) If either the angina or the hypertension remains uncontrolled. The combination of a -blocker and either of the nondihydropyridine CCBs (diltiazem or verapamil) should be used with caution in patients with symptomatic CAD and hypertension because of the increased risk of significant bradyarrhythmias and HF (Class IIa. and thiazide diuretic. Level of Evidence B). ACE inhibitor.

or lipid-lowering agents for the management of angina and the prevention of coronary events. especially those due to myocardial ischemia (Class IIa. Level of Evidence C). lowering SBP may cause very low DBP values (<60 mm Hg). If ventricular dysfunction is present. In patients with CAD.(4) The target BP is <130/80 mm Hg. Level of Evidence B). to <120/80 mm Hg. consideration should be given to lowering the BP even further. (5) There are no special contraindications in hypertensive patients to the use of nitrates. and caution is advised in inducing falls of DBP below 60 mm Hg. except that in uncontrolled severe hypertension in patients who are taking antiplatelet or anticoagulant drugs. antiplatelet or anticoagulant drugs. the BP should be lowered slowly. BP should be lowered without delay to reduce the risk of hemorrhagic stroke (Class IIa. . This should alert the clinician to assess carefully any untoward signs or symptoms. In older hypertensive individuals with wide pulse pressures.

. usually intravenously. then a nondihydropyridine CCB. may be substituted. or if the patient develops intolerable side effects of a -blocker. If the patient is hemodynamically unstable. such as verapamil or diltiazem. the initiation of -blocker therapy should be delayed until stabilization of HF or shock has been achieved. If the angina or the hypertension is not controlled with a -blocker alone. If there is a contraindication to the use of a -blocker. in addition to nitrates for symptom control. the initial therapy of hypertension should include shortacting 1. A thiazide diuretic can also be added for BP control (Class I. Alternatively. then a longer-acting dihydropyridine CCB may be added. Oral -blockers can be substituted at a later stage of the hospital stay (Class IIa. Level of Evidence B). oral -blockers may be started promptly without prior use of intravenous blockers (Class I.RECOMMENDATION FOR MANAGEMENT OF HYPERTENSION IN PATIENTS WITH ACUTE CORONARY SYNDROMES—UNSTABLE ANGINA AND NSTEMI (1) (2) In unstable angina or NSTEMI. but not if there is LV dysfunction.selective -blockers without intrinsic sympathomimetic activity. Diuretics can be added for BP control and for the management of HF (Class I. Level of Evidence A). Level of Evidence A). Level of Evidence B).

(3) If the patient is hemodynamically stable. or if the patient has diabetes mellitus. Level of Evidence A) or ARB (Class I. The target BP is <130/80 mm Hg. In older hypertensive individuals with wide pulse pressures. However. Level of hypertensive Evidence B). lowering SBP may cause very low DBP values (<60 mm Hg). (5) anticoagulants. or lipid-lowering agents for the management of acute coronary syndromes. especially those due to There are no special contraindications in worsening myocardial ischemia (Class IIa. if hypertension persists. if the patient has evidence of LV dysfunction or HF. This should alert the clinician to assess carefully any untoward signs or symptoms. Level of Evidence B) should be added if the patient has an anterior MI. and (4) caution is advised in inducing falls of DBP below 60 mm Hg. in patients with an elevated DBP and acute coronary syndrome. an ACE inhibitor (Class I. For the . patients to the use of nitrates. antiplatelet drugs. the BP should be lowered slowly.

oral -blockers may be started promptly without prior intravenous -blockers (Class I. However. Level of Evidence A). Initial therapy of hypertension can include shortacting 1-selective -blockers without intrinsic sympathomimetic activity. An ACE inhibitor (Class I. ACE inhibition has been found to be particularly beneficial in patients in whom the infarct is large and/or there is a history of previous infarction. the principles of therapy for hypertension are similar to those for unstable angina and NSTEMI as described above. HF. in addition to nitrates for symptom control (Class IIa. if the patient is hemodynamically unstable. ACE inhibitors and ARBs should not be given together because there is an increase in the incidence of adverse events without improving survival. or if hypertension persists or there is LV dysfunction. Level of Evidence B) should be administered early in patients with STEMI and hypertension. Diuretics can be added for BP control and for management of HF (Class I. the initiation of -blocker therapy should be delayed until stabilization of HF or shock has been achieved. Level of Evidence A). Alternatively. Level of Evidence B). and tachycardia. usually intravenously. HF. .MANAGEMENT OF HYPERTENSION IN PATIENTS WITH ACUTE CORONARY SYNDROMES—STEMI (1) (2) In STEMI. or diabetes mellitus. with some exceptions. particularly in anterior MI. Oral -blockers can be substituted at a later stage of the hospital stay. Level of Evidence A) or ARB (Class I.

0 mg/dL in women) or elevated potassium levels (5. or as adjunct therapy for BP control.0 mEq/L) (Class I.5 mg/dL in men. 2. These agents should be avoided in patients with elevated serum creatinine levels (2. Level of Evidence A).(3) Aldosterone antagonists may be useful in the management of STEMI with LV dysfunction and HF and may have an additive BPlowering effect. (4) CCBs do not reduce mortality rates in the setting of acute STEMI and can increase mortality if there is depressed LV function and/or pulmonary edema. Serum potassium levels must be monitored. Long-acting dihydropyridine CCBs can be used when -blockers are contraindicated or inadequate to control angina. Nondihydropyridine CCBs may be used for the treatment of patients with supraventricular tachycardia but should not be used in patients with bradyarrhythmias or impaired LV function (Class IIa. Level of Evidence B) .

lowering SBP may cause very low DBP values (<60 mm Hg). anticoagulant and antiplatelet drugs. BP should be lowered without delay in patients with uncontrolled hypertension who are taking antiplatelet or anticoagulant drugs (Class IIa.(5) As in patients with unstable angina/NSTEMI. however. Uncontrolled hypertension is a contraindication to fibrinolytic therapy because of the risk of intracranial hemorrhage. Level of Evidence C). In older hypertensive individuals with wide pulse pressures. in patients with an elevated DBP and STEMI. This should alert the clinician to assess carefully any untoward signs or symptoms. and caution is advised in inducing falls of DBP below 60 mm Hg. For the same reason. (6) . the BP should be lowered slowly. or lipid-lowering agents for the management of STEMI. There are no special contraindications in hypertensive patients to the use of nitrates. especially those due to worsening myocardial ischemia (Class IIa. the target BP in patients with STEMI is <130/80 mm Hg. Level of Evidence B).

Lifestyle Specific Drug mm Hg Modification Indications † <140/90 Yes Any effective antihypertensive drug or combination‡ Comments If SBP 160 mm Hg or DBP 100 mm Hg.SUMMARY OF MAIN RECOMENDATION Area of concern General CAD prevention BP Target. then start with 2 drugs High CAD risk* <130/80 Yes ACEI or ARB or CCB or thiazide diuretic or Combination B-Blocker and ACEI or ARB If SBP 160 mm Hg or DBP 100 mm Hg. can substitute diltiazem or verapamil (but not if bradycardia or LVD is present) . then start with 2 drugs Stable angina <130/80 Yes If -blocker contraindicated. or if side effects occur.

-blockers LVD <120/80 Yes ACEI or ARB and blocker and aldosterone antagonist¶ and thiazide or loop diuretic and hydralazine/isosorbide dinitrate (blacks) . clonidine.B If -blocker contraindicated. moxonidine.A thiazide diuretic can be added for BP control Contraindicated: verapamil.AoC STEMI BP Target <130/80 Lifestyle Modification† Yes Specific Drug Indications B-Blocker (if patient is hemodynamically stable) and ACEI or ARB Comments .Can add dihydropyridine CCB (not diltiazem or verapamil) to B-blocker . can substitute diltiazem or verapamil (but not if bradycardia or LVD is present) . or if side effects occur. diltiazem.

LVD.UA/NSTEMI <130/80 Yes B-Blocker (if patient is hemodynamically stable) and ACEI or ARB§ . §If anterior MI is present. *Diabetes mellitus. or if the patient has diabetes mellitus. ‡Evidence supports ACEI (or ARB).If B-blocker contraindicated. peripheral arterial disease.Can add dihydropyridine CCB (not diltiazem or verapamil) to B-blocker . . chronic kidney disease. †Weight loss if appropriate. if hypertension persists. Before making any management decisions. known CAD or CAD equivalent (carotid artery disease. healthy diet (including sodium restriction). or if side effects occur. or 10-year Framingham risk score 10% (see Appendix).A thiazide diuretic can be added for BP control UA indicates unstable angina. CCB. exercise. smoking cessation. can substitute diltiazem or verapamil (but not if bradycardia or LVD is present) . LV dysfunction. if LV dysfunction or HF is present. you are strongly urged to read the full text of the relevant section of the scientific statement. or thiazide diuretic as first-line therapy. abdominal aortic aneurysm). and alcohol moderation. ACE inhibitor. and ACEI.