Management of Hypertension in Patients with CAD M. Mohsen Ibrahim, MD Cardiology Department- Cairo University 1. What is the optimal BP in patients with hypertension and CAD? 2. What is the minimum safe level of DBP? 3. Do particular classes of drugs have protective actions beyond BP lowering? 4. Which antihypertensive drugs should be used in patients with established CAD? Stable angina. Unstable angina and non-st- elevation MI. ST-elevation MI. ١
The optimal BP in patients with hypertension and CAD CAD Prevention High CAD risk Stable angina UA/ NSTEMI STEMI LVD BP Target (mmhg) < 140/90 <130/80 <130/80 <130/80 <130/80 < 120/80 High CAD Risk Diabetes mellitus. Chronic kidney disease. Known CAD CAD equivalent: Carotid artery disease. Peripheral artery disease. Abdominal aortic aneurysm. 10-year Framingham risk score 10%. Metabolic syndrome ٢
CAMELOT Trial Blood Pressure and Coronary Disease Progression : IVUS SBP in range of 120 to 140 :no progression or regression of CAD Sipahi et al., 2006 Minimal Safe DBP In patients with high DBP and occlusive CAD with evidence of ischemia: Increased MI prevalence in those with achieved DBP of < 80 mmhg (Medical Research Council s Trial of mild hypertension) BP should be lowered slowly. Falls of DBP below 60 mmhg should be avoided if the patient has diabetes or is over the age of 60 years. ٣
Antihypertensive Drugs Mechanism Independent of the BP Lowering Effect Greater Anti-atherosclerotic Action Has not been demonstrated convincingly. For secondary prevention (CAD, CKD, or recurrent stroke): Not all drug classes has been proven to confer optimal benefit. Which Drug Class to Use in CAD Patients? INVEST Study Verapamil- Trandolapril was as clinically effective as atenolol- hydrochlorothiazide in hypertensive CAD patients- similar event rates. Primary outcome: death (all cause), non fatal MI, non fatal stroke after 24 months JAMA 2003 ٤
Hypertension in Patients with CAD Stable angina B-blockers: drugs of first choice. CCB: - added to BB when: 1. BP remains elevated 2. Angina persists - Substitute BB when: 1. Contraindication 2. Side effects ACE-I: high risk pateints (diabetes, LV syst dysfunction). ARBs: patients intolerant to ACE-I B-Blockers: Blockers: Indications Symptomatic CAD (angina) MI LV dysfunction ٥
ACE-inhibitors: Indications All patients after MI All patients with LV dysfunction Patients at high risk of CAD High risk CAD patients (diabetes, other risk factors) ACE-inhibitors: Clinical Trials Cardioprotection Definite HOPE EUROPA ANBP-2 No special advantage PEACE ALLHAT ٦
Hypertension in Patients with CAD Unstable angina and NSTEMI In patients presenting with persistent pain, and in absence of contraindications - BB should be started intravenously, followed by oral BB. - Cardioselective BB without ISA are preferably. - BB can be given to patients with mild to moderate reactive airway disease. - Non dihydropyridine CCB when BB are contraindicated. CCB in ACS Clinical Trials DAVIT (Danish Verapamil Infarction Trials) Reduction in death or non-fatal MI IV verapamil at admission and then orally for 1 week. DRS (Diltiazem Reinfarction Study) Reduction in reinfarction and refractory angina at 14 days Diltiazem 24-72 hrs after onset of NSTEMI. Avoid verapamil and diltiazem in patients with LV dysfunction. ٧
ACS- STEMI Principles therapy of HTN are similar to those for U/A and NSTEMI. Appropriate of treatment of HTN at presentation with STEMI - Few data are available. HTN is a relative contraindication to fibrinolysis IV nitroglycemia: - Acute HTN - Relieve ischemic pain - Pulmonary congestion IV BB: -Reduction in: - reinfarction and vent fibrillation. - Increase in cardiogenic shock Early ACE-I: particularly in ant MI, LV dysfunction, persistent HTN Acute severe HTN and Flash Pulmonary Edema IV Nitroglycerin No Tachycardia Tachycardia ± ischemia IV furosomide ACE-I: short acting IV esmolol IV furosomide IV nitroprusside ٨
HTN in HF of Ischemic Origin Limited evidence-based guidelines Patients presenting with HF: -older - more than half have a normal LVF Increased LV mass is associated with development of depressed LVF Drugs of choice: Thiazide diuretics + ACE-I Target BP: < 120/80 mmhg Drugs to avoid: Non dihydropyridine CCB Moxonidine and clonidine α-blockers to be used with caution Which Drug Class to Use in specific CAD Patients? Based on Additional Factor History of HF Diabetes risk Physician's best judgment ٩