title: Prognostic value of blood pressure in patients with high vascular risk in the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial study.
abstract: BACKGROUND
  Hypertension guidelines advise aggressive blood pressure (BP) lowering in patients with diabetes or high cardiovascular risk, but supporting evidence is limited. We analysed the impact of BP on cardiovascular events in well treated high-risk patients enrolled in a large clinical trial (Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial).
  
  
  METHODS
  Twenty-five thousand five hundred and eighty-eight patients with atherosclerotic disease or diabetes with organ damage, tolerant to angiotensin-converting enzyme inhibitors, were randomized to ramipril, telmisartan or both. We related the primary composite outcome and its components to: baseline SBP; SBP changes from baseline to event; and average in-trial SBP.
  
  
  RESULTS
  The risk of myocardial infarction did not increase with baseline SBP and was unaffected by subsequent SBP change. In contrast, stroke risk progressively increased with baseline SBP (P for trend <0.0001) and decreased with reduction. In patients with baseline SBP less than 130 mmHg, adjusted for several covariates, cardiovascular mortality increased with further SBP reduction (P < 0.0001). A J-curve (nadir around 130 mmHg) occurred in the relationship between in-treatment SBP and all outcomes except stroke.
  
  
  CONCLUSIONS
  In high-risk patients, the benefits from SBP lowering below 130 mmHg are driven mostly by a reduction of stroke; myocardial infarction is unaffected and cardiovascular mortality is unchanged or increased. Future trials should be designed to test the value of SBP lowering in high-risk patients with SBP in the range of 130-150 mmHg.
authors.affiliation: CV Medicine, John Radcliffe Hospital, Oxford, UK. peter.sleight@attglobal.net
authors.forename: Peter
authors.initials: P
authors.lastname: Sleight
authors.forename: Josep
authors.initials: J
authors.lastname: Redon
authors.forename: Paolo
authors.initials: P
authors.lastname: Verdecchia
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Mancia
authors.forename: Peggy
authors.initials: P
authors.lastname: Gao
authors.forename: Robert
authors.initials: R
authors.lastname: Fagard
authors.forename: Helmut
authors.initials: H
authors.lastname: Schumacher
authors.forename: Michael
authors.initials: M
authors.lastname: Weber
authors.forename: Michael
authors.initials: M
authors.lastname: Böhm
authors.forename: Bryan
authors.initials: B
authors.lastname: Williams
authors.forename: Janice
authors.initials: J
authors.lastname: Pogue
authors.forename: Teo
authors.initials: T
authors.lastname: Koon
authors.forename: Salim
authors.initials: S
authors.lastname: Yusuf
mesh_terms: D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001562:Benzimidazoles / Q000627:therapeutic use*; D001565:Benzoates / Q000627:therapeutic use*; D001794:Blood Pressure; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D017257:Ramipril / Q000627:therapeutic use*; D000077333:Telmisartan; D016896:Treatment Outcome
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents; D001562:Benzimidazoles; D001565:Benzoates; D017257:Ramipril; D000077333:Telmisartan