CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Peter F. Kokkinos, PhD*,
Steven Singh, MD and
Puneet Narayan, MD
* Veterans Affairs Medical Center/Cardiology, 50 Irving Street NW, Washington, DC 20422 (Email: peter.kokkinos{at}med.va.gov).
We appreciate Drs. Bangalore and Messerli’s interest in our study (1). In their letter to the editor they argue that our statement—"for patients engaging in vigorous activities ... ß-blockade-based therapy can protect against excessive and repetitive elevations in blood pressure (BP) which may occur during such activities"—may be inappropriate because it is based on peripheral BP measurements. They present evidence for greater risk of cardiovascular events or lower-risk reduction with beta-blockers versus other antihypertensive agents (2–4) and they suggest that this lower risk is due to lower central BP achieved by antihypertensive agents other than beta-blockers, as supported by the 4.3-mm Hg lower central BP reported in the CAFÉ trial (4). Finally, they suggest that for hypertensive patients "we do need a medication that curtails their (central) BP rise but not one that curtails their activity."
We agree that beta-blockers are not as effective in reducing stroke rates when compared to other antihypertensive agents. However, it is important to point out that there are no data on therapies and outcomes in hypertensive patients with an exaggerated BP response to exercise.
Our statement is based on observations that the exercise BP on those treated with beta-blockers was 14–19 mm Hg lower at different workloads and for different antihypertensive agents. Most will agree that the relationship between central and peripheral BP is direct, and a change in one (central or peripheral) will result in a proportional change in the same direction on the other. Therefore, it is reasonable to assume that a peripheral exercise BP that is 14–19 mm Hg lower than the BP of those treated with antihypertensive agents other than beta-blockers is more likely to reflect a proportionally lower than higher central BP.
We also agree that beta-blockers reduce exercise time. The peak exercise time in our patients on beta-blocker-based therapy was lower by 19 s compared to the other agents. However, we are confident that most health care providers and patients will gladly trade 19-s reduction in peak exercise time for 19-mm Hg lower systolic BP during physical activities.
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1. Kokkinos P, Chrysohoou C, Panagiotakos D, Narayan P, Greenberg M, Singh S. Beta-blockade mitigates exercise blood pressure in hypertensive male patients J Am Coll Cardiol 2006;47:794-798.[Abstract/Free Full Text]2. Dahlof B, Sever PS, Poulter NR, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial–Blood Pressure Lowering Arm (ASCOT–BPLA): a multicentre randomised controlled trial Lancet 2005;366:895-906.[CrossRef][Web of Science][Medline] 3. Lindholm LH, Carlberg B, Samuelsson O. Should beta-blockers remain first choice in the treatment of primary hypertension?A meta-analysis. Lancet 2005;366:1545-1553.[CrossRef][Web of Science][Medline] 4. Williams B, Lacy PS, Thom SM, et al. Differential impact of blood pressure-lowering drugs on central aortic pressure and clinical outcomesPrincipal results of the Conduit Artery Function Evaluation (CAFE) study. Circulation 2006;113:1213-1225.[Abstract/Free Full Text]
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