Optimal blood pressure in LEAD patients?

Association of blood pressure measurements with peripheral arterial disease events. Reanalysis from the ALLHAT data.

Recently the ESC/ESH Guidelines on management of arterial hypertension have been published and one year earlier the AHA/ACCP Guidelines have been published [1, 2]. Recommendations are based on results of the SPRINT study (Systolic Blood Pressure Intervention Trial) [3]. In this trial lower blood pressure was associated with a reduction in cardiovascular events but also associated with a higher percentage of acute renal failure. This rise the question whether current recommendations for target blood pressure can be used also in patients with peripheral atherosclerosis.

In a current publication association of blood pressure with peripheral arterial disease events has been reported from the ALLHAT trial (Antihypertensive and Lipid lowering Treatment to prevent Heart Attack Trial) [4, 5]. In this reanalysis 33 357 patients from the ALLHAT trial have been included and PAD events were assessed. PAD events were defined as PAD related hospitalization, procedures, medical treatment, or PAD related death. Both higher (>=160 mmHg) as well as lower (<120 mmHg) systolic blood pressure was associated with a higher rate of PAD events compared to patients with a systolic blood pressure between 120 and 129 mmHg.

So far evidence for blood pressure treatments targets in patients with lower extremity arterial disease (LEAD) in limited. Lower blood presser might increase leg ischemia in particular in patients with advanced LEAD, therefore the use of the same values in these patients seems questionable. The results of the ALLHAT reanalysis implicates that in LEAD patients is seems very important to avoid to high or to low blood pressure. In contrast a current meta-analysis did not found worsening of clinical symptoms in LEAD patients [6]. In addition, results from the HOPE study (Heart Outcomes Prevention Evaluation) suggested that in particular LEAD patients benefit from blood pressure control with regard to cardiovascular events [7].

In summary there is no doubt that LEAD patients with arterial hypertension need blood pressure control to improve their cardiovascular prognosis.