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Optimal blood pressure in LEAD patients?

Commented by Christine Espinola-Klein; section Peripheral Arterial Disease

Cardiology
Prevention


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. 

References


  1. Williams B, Mancia G, Spiering W et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. European Heart Journal 2018, 1–98.
  2. Whelton PK, Carey RM, Aronow WS et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. J Am Coll Cardiol 2018; 71: e 127-e248.
  3. Wright JT, Williamson JD, Whelton PK et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2015; 373: 2103-2116.
  4. Itoga N, Twafik DS, Lee CK, et al. Association of blood pressure measurements with peripheral arterial disease events. Reanalysis from the ALLHAT data. Circulation 2018; 138: 1805-1814.
  5. Fudim M, Jones WS. New curveball for hypertension guidelines? Blood pressure targets in peripheral arterial disease. Editorial Circulation 2018; 138: 1815-1818.
  6. Manapurathe T, Krishna SM, Dewdney B, et al. Effect of blood pressure lowering medications on leg ischemia in peripheral artery disease patients: a meta-analysis of randomized controlled trials. PLOS one 2017; 12: e0178713.
  7. Ostergren J, Sleight P, Dagenias G, et al. Impact of ramipril in patients with evidence of clinical or subclinical peripheral arterial disease. Eur Heart J 2004; 25: 17-24.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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