ABSTRACT
Recently, the Action to Control Cardiovascular Risk in Diabetes (ACCORD) blood pressure (BP) trial enrolled 4733 participants with type 2 diabetes and randomized them to a target systolic blood pressure (SBP) of less than 120 mm Hg or 140 mm Hg. Despite the significant difference in the achieved SBP, there was no significant difference in the incidence of primary outcomes. Based on this evidence, the target SBP for diabetics has been revised in the majority of major guidelines. However, there is a steeper association between SBP and stroke in Asians than other ethnicities, with stroke being the leading cause of cardiovascular mortality. This suggests that target BP in the Asian region should be tailored towards prevention of stroke. In the ACCORD study, the intensive BP treatment was associated with significant reductions in both total stroke and non-fatal stroke. The results from the ACCORD study are supported by a subgroup analysis from the ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) study, which showed that, in diabetic patients, the risk of stroke continues to decrease to a SBP value of 115 mm Hg with no evidence of J curve. As diabetes is highly associated with underlying coronary artery disease, there is a justified concern for adverse effects resulting from too much lowering of BP. In a post hoc analysis of 6400 diabetic subjects enrolled in the International Verapamil SR-Trandolapril (INVEST) study, subjects with SBP of less than 110 mm Hg were associated with a significant increase in all-cause mortality. In the ONTARGET study, at any levels of achieved SBP, diastolic blood pressure (DBP) below 67 mm Hg was associated with increased risk for cardiovascular outcomes. As such, a prudent approach would be to target a SBP of 130–140 mm Hg and DBP of above 60 mm Hg in diabetics with coronary artery disease. In conclusion, hypertension, in association with diabetes, has been found to be significantly correlated with an elevated risk for cardiovascular events. As the association between stroke and BP is stronger in Asians, compared to other ethnicities, consideration should be given for a target BP of 130/80 mm Hg in Asians.
Subject(s)
Humans , Asian People , Blood Pressure , Coronary Artery Disease , Hypertension , Incidence , Mortality , Ramipril , Stroke , VerapamilABSTRACT
A Hipertensão Arterial é uma patologia de grande prevalência em nosso meio e que contribui de forma importante como o maior fator de risco independente para o desenvolvimento de Acidente Vascular Cerebral (AVC) e Doença Arterial Coronária (DAC). Atualmente, a DAC representa a maior causa de mortalidade cardiovascular em nosso país. Portanto, a busca de controle das cifras pressóricas em hipertensos com DAC ou com risco de desenvolvê-la torna-se um objetivo. Que metas devemos atingir nesse tipo de paciente? Recente estudos modificaram esses valores, que devem situar entre 130 139/85 89 mmHg. Reduções mais intensas podem aumentar o risco de eventos, com especial atenção para não reduzir a pressão arterial diastólica (PAD) abaixo de 60 mmHg. Grande benefício decorre da redução da PA per se, devendo ser fortemente implementada, em todos os pacientes, a modificação no estilo de vida associada a esquemas medicamentosos. Sabidamente, algumas classes de anti-hipertensivos têm uma indicação compulsória nessa situação, a saber, os Beta-bloqueadores (BB), os Inibidores da Enzina Conversora de Angiotensina (IECA), os Bloqueadores dos Receptores da Angiotensina (BRA) e os Bloqueadores dos Canais de Cálcio (BCC). Da mesma forma, podemos utilizar as associações desses fármacos na busca de um melhor controle da PA, sendo inclusive uma opção de início de tratamento, uma vez que estamos diante de pacientes de alto ou muito alto risco.
Hypertension is a disease of high prevalence in Brazil and contributes significantly as the largest independent risk factor for the development of stroke and coronary artery disease (CAD). Currently, CAD is the major cause of cardiovascular mortality in Brazil. Therefore, the search for the control of blood pressure levels in hypertensive patients with CAD or with risk for developing it becomes a target. What goals should we achieve in this type of patient? Recent studies have modified these values that should be in the range of 130 139/85 89 mmHg. Larger decreases may increase the risk for events, with special care to not reduce diastolic blood pressure (DBP) below 60 mmHg. Great benefit results from reduction of BP per se, and the modification in life style, associated with drug regimens, must be strongly implemented in all patients. It is known that some classes of antihypertensive drugs have a compelling indication in this situation, as Beta-blockers (BB), Angiotensin-Converting Enzyme Inhibitors (ACEI), Angiotensin Receptor Blockers (ARB) and Calcium Channel Blockers (CCB). Likewise, we can use the association of these drugs in search for a better BP control, being inclusively an option of early treatment, since we are dealing with patients at high or very high risk.
Subject(s)
Coronary Artery Disease , HypertensionABSTRACT
Existem evidências suficientes de que a hipertensão não controlada aumenta a morbidade cardiovascular e de que baixar a pressão arterial pode reduzir tal evento. O "quanto mais baixa melhor" tem sido um conceito para a maioria dos médicos nos últimos 30 anos. Este artigo abordou criticamente o "paradoxo da curva J", indicando que a redução da pressão arterial sistólica abaixo de 120 ou 125 mmHg e a pressão arterial diastólica abaixo de 70 ou 75 mmHg são caracterizadas pelo aumento, ao invés de redução, de eventos coronários. Esses aspectos são relevantes em pacientes idosos, nos quais a presença de doença arterial coronária requer cuidados especiais em baixar a pressão arterial. Foram destacadas algumas questões: o contexto histórico do fenômeno da "curva J" e os ensaios clínicos a favor ou contra a existência da "curva J "em pacientes hipertensos.
There are enough evidences that uncontroled hypertension increases cardiovascular morbidity and that lowering elevated blood pressures can reduce this event. "Lower the better" has been a concept most of the physicians over the last 30 years. This paper critically addressed the issue of the "J curve" paradox the finding indicating that treatment-induced systolic blood pressure values below 120 or 125 mmHg and diastolic blood pressure values below 75 or 70 mmHg are characterized by an increase, rather than a reduction, in the incidence of coronary events. These aspects are relevant in elderly patients, in whom the presence of coronary artery disease requires special care in lower blood pressure. Some subjects were highlighted: the historical background of a "J-curve" and clinical trials for or against the existence of a "J curve" in hypertensive patients.
Subject(s)
Humans , Male , Female , Coronary Artery Disease , HypertensionABSTRACT
The J-curve effect describes an inverse relation between low blood pressure (BP) and cardiovascular complications. This effect is more pronounced in patients with preexisting coronary artery disease (CAD), hypertension or left ventricular hypertrophy (LVH). The recent large clinical outcomes trials have observed a J-curve effect between a diastolic BP of 70-80 mmHg as well as a systolic BP <130 mmHg. The J-curve phenomenon does not appear in stroke or renal disease. This is because the coronary arteries are perfused during diastole, but the cerebral and renal perfusion mainly occurs in systole. Therefore, caution should be taken to maintain the diastolic blood pressure (DBP) at minimum of 70 mmHg and possibly to maintain the DBP between 80-85 mmHg in patients with severe LVH, CAD or vascular diseases. BP control in high-risk elderly patients should be carefully done as undergoing aggressive therapy to lower the systolic blood pressure below 140 mmHg can cause cardiovascular complications due to the severely reduced DBP and increased pulse pressure.