Physician’s Weekly: online CME courses, articles on hypertension, arthritis

The American Heart Association (AHA) recently published a scientific statement with the goal of helping prevent coronary artery disease (CAD) in patients with hypertension and for treating hypertension in patients with established CAD. The AHA’s review, published in the May 2007 issue of Circulation, distinguishes itself from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), and other previously established management recommendations. The new statement recommends lower target blood pressure (BP) goals in high-risk patients and in those with established CAD. The new statement also excludes ß-blockers as a drug therapy option for the prevention of the disease.

Key Recommendations for a Lower BP Target

The JNC 7 guidelines recommend a general BP target of 140/90 mm Hg and a target of less than 130/80 mm Hg in patients with diabetes or chronic kidney disease. We need to be more aggressive than that. It is now recommended that all high-risk patients be treated to lower BP levels—130/80 mm Hg or less. The definition for high-risk CAD has also been expanded to include carotid artery disease, peripheral arterial disease, abdominal aortic aneurysm, and patients with a 10-year Framingham risk score of 10% or greater. The Framingham study is a quick assessment of coronary risk based on a number of factors, but relies heavily on age. Patients with established CAD should also have a BP target less than 130/80 mm Hg. In addition, patients with left ventricular dysfunction are recommended to an even more aggressive BP target of 120/80 mm Hg or less.

A Closer Look at the Role of ß-Blockers

Our recent AHA statement excluded ß-blockers as monotherapy or first-line therapy in patients at high risk of developing CAD because the evidence of cardio-protection and protection from stroke with these drugs is either nonexistent or very weak. All ß-blockers lower BP, but they seem to be less effective than other antihypertensive drugs in reducing mortality, myocardial infarction, and stroke in uncomplicated hypertensive patients. It’s conceded that most of the trials have used atenolol; it may be that other members of this very heterogeneous class of ß-blockers will have a better record in reducing cardiovascular events.

On the other hand, once CAD manifests, ß-blockers assume center stage; these drugs are still the cornerstone of treatment in patients with stable and unstable angina as well as in post-myocardial infarction and heart failure. ß-blockers effectively lower BP, provide symptomatic relief from angina, and are cardio-protective. While ß-blockers seem to be less effective than other drugs in preventing CAD (and stroke) in uncomplicated hypertension, these drugs are clearly effective in the management of hypertension in patients with established CAD.

Strategies to Maintain Lower BP Levels

Although specific drug use remains controversial, there is convincing evidence to support use of an angiotensin-converting enzyme inhibitor, angiotensin II receptor blocker, calcium channel blocker, or thiazide diuretic as first-line therapy for high-risk patients. These drugs should be supplemented by a second agent if BP control is not achieved by monotherapy. Most patients will require two or more drugs to reach their BP goal. Patients also need to be instructed to attend follow-up visits every 2 or 3 weeks for dose adjustments and/or for the addition of more drugs (if necessary) until the target BP is achieved. Oftentimes patients are put on therapy and told to return in a few months—a lack of close monitoring is one of the many reasons why good BP control has not been achieved in higher numbers.

Dr. Rosendorff has indicated to Physician’s Weekly that he has or has had the following financial interest: Siemens Diagnostics, Astra Zeneca, Cardiovascular Therapeutics, Schering-Plough, Bristol-Myers Squibb, Merck, Daiichi-Sankyo Pharmaceutical.