Hypertension: Which drugs to choose for patients with cardiovascular disease

,

Applied Evidence

Hypertension: Which drugs to choose for patients with cardiovascular disease

J Fam Pract. 2006 April;55(4):291-298

By

Randy Wexler, MD, MPH, FAAFP

Recommendations for heart failure, coronary artery disease, and stroke.

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References

1. American Heart Association. Heart Disease and Stroke Statistics–2004 Update. Dallas, Tex: American Heart Association, 2003.

2. Ogden LG, He J, Lydick E, Whelton P. Long-term absolute benefit of lowering blood pressure in hypertensive patients according to JNC VI risk stratification. Hypertension 2000;35:539-543.

3. Hansson L, Lindholm L, Ekbom T, et al. Randomised trial of old and new antihypertensive drugs in elderly patients: cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension-2 study. Lancet 1999;354:1751-1756.

4. Turnbull F. Blood Pressure Lowering Treatment Trialists’ Collaboration. Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomized trials. Lancet 2003;362:1527-1535.

5. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903-1913.

6. Vasan RS, Larson MG, Leip EP, et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med 2001;345:1291-1297.

7. Whelton P, He J, Appel L, et al. National High Blood Pressure Education Program Coordinating Committee. Primary prevention of hypertension: Clinical and public health advisory from the National High Blood Pressure Education Program. JAMA 2002;288:1882-1888.

8. The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991;325:293-302.

9. Pfeffer MA, Braunwald E, Moye LA, et al. The SAVE Investigators. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. N Engl J Med 1992;327:669-677.

10. Flather MD, Yusuf S, Kobler L, et al. ACE-Inhibitor Myocardial Infarction Collaboration Group. Long-term ACE inhibitor therapy in patients with heart failure or left ventricular dysfunction: A systematic overview of data from individual patients. Lancet 2000;355:1575-1581.

11. Chobanian A, Bakris G, Black H, et al. Seventh Report of The Joint National Committee on Prevention, Detection, Evaluation, and Management of High Blood Pressure (JNC-7). Hypertension 2003;42:1206-1252.

12. Hunt S, Abraham WT, Chin M, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart failure in the Adult. A report of the American College of Cardiology/American Heart Association task force on practice guidelines. Writing to update the 2001 guidelines for the evaluation and management of heart failure, 2005, available at www.acc.org, accessed 10-19-05.

13. Dargie HJ. Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomized trial. Lancet 2001;357:1385-1390.

14. Packer M, Coats A, Fowler MB, et al. Carvedilol Prospective Randomized Cumulative Survival Study Group. Effect of carvedilol on survival in severe chronic heart failure. N Engl J Med 2001;344:1651-1658.

15. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet 1999;353:2001-2007.

16. Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patents with severe heart failure. Randomized Aldactone Evaluation Study (RALES) Investigators. N Engl J Med 1999;341:709-717.

17. Pitt B, Remme WJ, Zannad F, et al. Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival (EPHESUS) Study Investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003;14:1309-1321.

18. Beta-Blocker Heart Attack (BHAT) Research Group. A randomized trial of propranalol in patients with acute myocardial infarction, I: mortality results. JAMA 1982;247:1707-1714.

19. Timolol-induced reduction in mortality and reinfarction in patients surviving acute myocardial infarction. N Engl J Med 1981;304:801-807.

20. Nissen SE, Tuzcu EM, Libby P, et al. Effect of antihypertensive agents on cardiovascular events in patients with coronary disease and normal blood pressure. The CAMELOT Study: a randomized controlled trial. JAMA 2004;292:2217-2226.

21. The Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. Effects of an angiotensin-converting enzyme inhibitor, ramipril, on cardiovascular events in high risk patients. N Engl J Med 2000;342:145-153.

22. The EURopean trial On reduction of cardiac events with Perindopril in stable coronary Artery disease Investigators. Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease; randomized, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet 2003;362:782-788.

23. PROGRESS Collaborative Group. Randomised trial of a perindopril based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischemic attack. Lancet 2001;358:1033-1041.

24. CIBIS Investigators and Committees. A randomized trial of beta blockade in heart failure. The Cardiac Insufficiency Bisoprolol Study (CIBIS). Circulation 1994;90:1765-1773.

25. Brassuer L. Experts challenge present hypertension guidelines. Intern Med 2005;6:1-and 8.-

26. Hyman DJ, Pavlik VN. Self-reported hypertension treatment practices among primary care physicians: Blood pressure thresholds, drug choices, and the role of guidelines and evidence based medicine. Arch Intern Med 2000;160:2281-2286.

27. Poole-Wilson P, Swedberg K, Cleland J, et al. Comparison of carvedilol and metoprolol on clinical outcomes in patients with chronic heart failure in the Carvedilol Or Metoprolol European Trial (COMET): randomized controlled trial. Lancet 2003;362:7-13.

28. Pitt B, Poole-Wilson PA, Segal R, et al. Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomized trial. The Losartan Heart Failure Survival Study ELITE II. Lancet 2000;355:1582-1587.

29. Cohn JN, Tognoni G. Valsartan Heart Failure Trail (VAL-HEFT) Investigators. A randomized trial of the angiotensin receptor blocker valsartan in chronic heart failure. N Engl J Med 2001;345:1667-1675.

30. Young JB, Dunlap ME, Pfeffer MA, et al. Mortality and morbidity reduction with candesartan in patients with chronic heart failure and left ventricular systolic dysfunction: results of the CHARM low-left ventricular ejection fraction trials. Circulation 2004;110:2618-2626.

31. The PEACE Trial Investigators. Angiotensin-converting enzyme inhibition in stable coronary artery disease. N Engl J Med 2004;351:2058-2068.

32. Kober L, Torp-Pedersen, Carlsen JE, et al. for the TRACE study group. A clinical trial of the angiotensin-converting enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial dysfunction. N Engl J Med 1995;333:1670-1676.

33. Ambrosioni E, Borghi C, Magnani B. For the SMILE Study Group. The effect of the angiotensin-converting enzyme inhibitor zofenopril on mortality and morbidity after myocardial infarction. N Engl J Med 1995;332:80-85.

34. Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. J Fam Pract 2004;53:111-120.

Practice recommendations

Decreasing blood pressure by 5 mm Hg will decrease mortality due to stroke by 14%, attenuate cardiac mortality by 9%, and reduce all-cause mortality by 7% (A).
Patients with heart failure should receive angiotensin-converting enzyme inhibitors if they are clinically tolerated (A). Beta-blockers are also recommended (A). Although aldosterone antagonists are appropriate for use in patients with heart failure (A), we recommend they are taken under the care of a cardiologist to minimize complications and to insure that a complete heart failure plan is in place (C).
For coronary artery disease, it is now considered standard of care to add a beta-blocker to all patients post–MI that do not have severe heart block or are in cardiogenic shock (A).
Perindopril plus indapamide should be used in all patients with a history of stroke or transient ischemic attack regardless of blood pressure (B).

Hypertension precedes more than 75% of heart failure cases and 50% of heart attacks. In 67% of first-time strokes, blood pressure exceeds 140/90 mm Hg.¹ For those in heart failure or at risk of recurrent myocardial infarction (MI) or stroke, the need to reduce unrecognized or under-treated hypertension is urgent. Thankfully it is possible to select an agent that can lower blood pressure—the most important immediate goal—and confer benefit to the associated cardiovascular disorder.

Given the number of agents used for both hypertension and other cardiovascular conditions, we sought in this study to evaluate which drug classes would best achieve blood pressure treatment goals and reduce morbidity and mortality for patients with cardiac disease. In this article, you will find practical recommendations for drug selection and appropriate regimens.

Even small blood pressure reductions yield big benefits for comorbidities

Using the population of the National Health and Nutrition Examination Survey I Epidemiologic Follow Up Study, Ogden and colleagues² found that the benefit of treating high blood pressure over a decade depended on lowering systolic blood pressure and on treating other relevant cardiovascular comorbidities. Specifically, the number needed to treat (NNT) and prevent a death was directly related to the risk stratification of patients and their initial blood pressure (TABLE W1) (LOE: 1).

In another provocative trial, the Swedish Trial in Old Patients with Hypertension-2 Study (STOP Hypertension-2)³ evaluated the use of beta-blockers, diuretics, angiotensin-converting enzyme (ACE) inhibitors, or calcium channel blockers. Results of this trial showed that an overall reduction in cardiovascular events related to the ability of a drug class to lower blood pressure (LOE: 1).³

FAST TRACK

A small reduction in blood pressure will yield a very significant reduction in risk from cardiovascular disease

In addition, a meta-analysis of 29 randomized trials (n=162,341) in the Blood Pressure Lowering Treatment Trialists’ Collaboration Trial (BPLTTC)⁴ showed that all antihypertensive drug classes significantly reduce blood pressure. This meta-analysis confirmed an overall reduction in cardiovascular events, with perceived risk reduction directly proportional to blood pressure reduction (LOE: 1). This advantage was consistent irrespective of drug class (beta-blocker, diuretic, ACE inhibitor, calcium-channel blocker, or angiotensin receptor blocker [ARB]), although different drug classes were recognized to have unique benefits specific to individual patient populations.

Should the BP target level be lowered? Recent evidence suggests that the currently accepted range for normal blood pressure may be too high.^5,6

Lewington and colleagues performed a meta-analysis of 61 prospective studies with more than 1 million participants. Using a “time-dependent” correction for regression dilution, they sorted deaths in each decade of age according to estimated blood pressures at the start of the decade (LOE: 1).⁵ They found that with each decade of life there was a proportional decline in the risk of cardiovascular deaths when blood pressures were controlled incrementally to levels of 115 mm Hg systolic blood pressure and 75 mm Hg diastolic blood pressure (LOE: 1).⁵ At blood pressures below 115/75 mm Hg, no difference was observed.

In addition, Vasan and collaborators,⁶ using the Framingham Heart Study database (n=6859 participants), reported an increase in cardiovascular events with higher baseline levels of blood pressure. When compared with optimal blood pressure levels, those with high-normal blood pressure (130–139/85–89 mm Hg) had a risk-factor-adjusted hazard ratio for cardiovascular disease of 2.5 for women and 1.6 for men (LOE: 1).⁶

The “take-home” message. A small reduction in blood pressure yields a very significant risk reduction. Decreasing blood pressure by 5 mm Hg will decrease mortality due to stroke by 14%, cardiac mortality by 9%, and all cause mortality by 7% (LOE: 1).⁷ These data suggest that aggressive intervention to affect small changes might affect large differences in morbidity and mortality.