CORRESPONDENCE: LETTER TO THE EDITOR
Blood Pressure Levels on Progression of Coronary Atherosclerosis
Franz H. Messerli, MD*,
Giuseppe Mancia, MD,
C. Richard Conti, MD and
Carl J. Pepine, MD
* St. Luke’s–Roosevelt Hospital Center, Division of Cardiology, 1000 Tenth Avenue, 3B-30, New York, New York 10019 (Email: fmesserli{at}aol.com).
The provocative study by Sipahi et al. (1) looking at progressions of coronary artery disease (CAD) in hypertension by intravascular ultrasound (IVUS) and the accompanying editorial by Tobis and Fonarow (2) do not quite clearly distinguish between the effects of blood pressure (BP) lowering on prevention or progression of CAD and the effects of BP lowering as a treatment modality in patients with manifest CAD. There is little surprise that the lower the BP, the better CAD will be prevented or its progression reversed. Numerous clinical and experimental low BP models are characterized by little, if any, atheromatosis in the exposed vascular bed. In fact, to put it pointedly, a zero BP would probably eliminate CAD completely. However, in patients with established CAD, several studies have shown that lowering diastolic pressure below certain levels will increase the risk of acute coronary events.
Based on our recent findings of a subanalysis of the 22,000-patient INVEST (International Verapamil-Trandolapril Study) (3), we would like to caution about too aggressive BP lowering in hypertensive patients with CAD. This holds particularly true for diastolic pressure and less so for systolic pressure. In the INVEST study (3), the nadir for primary outcome (all-cause death and total myocardial infarction) was J-shaped, with a nadir at 119/84 mm Hg (3). When diastolic pressure dropped below 70 mm Hg the adjusted hazard ratio of primary outcome doubled, and below 60 mm Hg it quadrupled. Because the coronary arteries are perfused during diastole only, coronary perfusion may become hampered when diastolic pressure falls excessively in patients at risk (i.e., those with CAD). Of note, in the study by Sipahi et al. (1) only systolic but not diastolic pressure was a significant determinant of progression of CAD. Thus, their concluding statement that "the most favorable rate of progression of coronary atherosclerosis is observed in patients whose BP falls within the "normal" Joint National Commission-7 category (i.e., systolic BP <120 mm Hg and diastolic BP <80 mm Hg)" and that "the optimal BP goal may be substantially lower than the <140/90 mm Hg" should be amended by refraining from identifying any levels of diastolic pressure.
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1. Sipahi I, Tuzcu EM, Schoenhagen P, et al. Effects of normal, pre-hypertensive, and hypertensive blood pressure levels on progression of coronary atherosclerosis J Am Coll Cardiol 2006;48:833-838.[Abstract/Free Full Text]2. Tobis J, Fonarow GC. Optimal blood pressure levels in patients with coronary artery disease J Am Coll Cardiol 2006;48:839-840.[Free Full Text] 3. Messerli FH, Mancia G, Conti CR, et al. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med 2006;144:884-893.[Abstract/Free Full Text]
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