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AHA scientific statement: new blood pressure targets for high-risk and established coronary artery disease patients.

AHA SCIENTIFIC STATEMENT: NEW BLOOD PRESSURE TARGETS FOR HIGH-RISK AND ESTABLISHED CORONARY ARTERY DISEASE PATIENTS The American Heart Association (AHA) Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention recently published a scientific statement on the “Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease.” The goal of this scientific statement was to make recommendations for the treatment of high blood pressure (BP) in adult men and women either with or at risk for ischemic heart disease (IHD). In making these first-ever recommendations, the authors attempted to synthesize and summarize the best available evidence; where data were meager or lacking, the authors have proposed consensus recommendations. Recommendations are provided for patients in the following 6 categories: 1. General coronary artery disease (CAD) prevention 2. High CAD risk, defined as the presence of diabetes mellitus, chronic kidney disease (CKD), CAD equivalents (carotid disease, peripheral arterial disease [PAD], abdominal aortic aneurysm [AAA]), or calculated 10-year Framingham Risk Score (FRS) of at least 10% 3. Stable angina 4. Unstable angina/non-ST elevation myocardial infarction (UA/NSTEMI) 5. ST-segment elevation myocardial infarction (STEMI) 6. Left ventricular (LV) dysfunction For most adults with hypertension, a BP target of <140/90 mm Hg is recommended for general CAD prevention (category 1). For patients with high CAD risk (as defined above), stable angina, UA/NSTEMI, and STEMI (categories 2–5), however, the recommended BP target is <130/80 mm Hg. For those with LV dysfunction (category 6), the recommended BP target is <120/80 mm Hg. Additionally, in patients with established CAD and LV dysfunction, the BP should be lowered slowly, and caution is advised in reducing diastolic BP below 60 mm Hg, especially in older individuals and those with diabetes. Each BP target was considered a class IIa recommendation, meaning that the weight of evidence/opinion is in favor of usefulness/efficacy, with level of evidence of B (data derived from a single randomized trial or nonrandomized studies) or C (only consensus opinion of experts, case studies, or standard of care exists). The second set of recommendations deals with indications for specific classes of antihypertensive medication. For primary prevention and high–CAD risk patients, an angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker (ARB), calcium channel blocker (CCB), thiazidetype diuretic, or combination is recommended as initial therapy. This is a class I recommendation, meaning there is evidence and/or general agreement of benefit, usefulness, and effectiveness, with level of evidence A (data derived from multiple randomized clinical trials or meta-analyses). In patients with stable angina, UA/NSTEMI, and STEMI, these recommendations call for use of a β-blocker and either an ACE inhibitor or ARB (class I; level of evidence A for most with some class IIa and/or level of evidence B). If a β-blocker is contraindicated or not tolerated, the prescriber can substitute a nondihydropyridine CCB (diltiazem or verapamil) if tolerated (class IIa; level of evidence B). If further BP control is needed, thiazide-type diuretics and/or dihydropyridine CCBs From the Division of General Internal Medicine/ Division of Cardiology, University of Nevada School of Medicine, Reno, NV;1 the Risk Reduction Center, Saint Mary’s Regional Medical Center, Reno, NV;2 the Primary Care Service Line, Ralph H. Johnson VA Medical Center, Charleston, SC;3 and the Division of General Internal Medicine/Geriatrics, Medical University of South Carolina, Charleston, SC4 Address for correspondence: Michael J. Bloch, MD, Risk Reduction Center, Saint Mary’s Regional Medical Center, 645 North Arlington Street, Suite 460, Reno, NV 89503 E-mail: mbloch@aol.com