Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease.
BACKGROUND
Hypertension guidelines advocate treating systolic blood pressure (BP) to less than 130 mm Hg for patients with diabetes mellitus; however, data are lacking for the growing population who also have coronary artery disease (CAD).


OBJECTIVE
To determine the association of systolic BP control achieved and adverse cardiovascular outcomes in a cohort of patients with diabetes and CAD.


METHODS
Observational subgroup analysis of 6400 of the 22,576 participants in the International Verapamil SR-Trandolapril Study (INVEST). For this analysis, participants were at least 50 years old and had diabetes and CAD. Participants were recruited between September 1997 and December 2000 from 862 sites in 14 countries and were followed up through March 2003 with an extended follow-up through August 2008 through the National Death Index for US participants.


METHODS
Patients received first-line treatment of either a calcium antagonist or beta-blocker followed by angiotensin-converting enzyme inhibitor, a diuretic, or both to achieve systolic BP of less than 130 and diastolic BP of less than 85 mm Hg. Patients were categorized as having tight control if they could maintain their systolic BP at less than 130 mm Hg; usual control if it ranged from 130 mm Hg to less than 140 mm Hg; and uncontrolled if it was 140 mm Hg or higher.


METHODS
Adverse cardiovascular outcomes, including the primary outcomes which was the first occurrence of all-cause death, nonfatal myocardial infarction, or nonfatal stroke.


RESULTS
During 16,893 patient-years of follow-up, 286 patients (12.7%) who maintained tight control, 249 (12.6%) who had usual control, and 431 (19.8%) who had uncontrolled systolic BP experienced a primary outcome event. Patients in the usual-control group had a cardiovascular event rate of 12.6% vs a 19.8% event rate for those in the uncontrolled group (adjusted hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.25-1.71; P < .001). However, little difference existed between those with usual control and those with tight control. Their respective event rates were 12.6% vs 12.7% (adjusted HR, 1.11; 95% CI, 0.93-1.32; P = .24). The all-cause mortality rate was 11.0% in the tight-control group vs 10.2% in the usual-control group (adjusted HR, 1.20; 95% CI, 0.99-1.45; P = .06); however, when extended follow-up was included, risk of all-cause mortality was 22.8% in the tight control vs 21.8% in the usual control group (adjusted HR, 1.15; 95% CI, 1.01-1.32; P = .04).


CONCLUSIONS
Tight control of systolic BP among patients with diabetes and CAD was not associated with improved cardiovascular outcomes compared with usual control.


BACKGROUND
clinicaltrials.gov Identifier: NCT00133692.
Cooper-DeHoff
Rhonda M
RM
Department of Pharmacotherapy and Translational Research and Division of Cardiovascular Medicine, College of Pharmacy, University of Florida, 1600 SW Archer Rd, PO Box 100486, Gainesville, FL 32610-0486, USA. dehoff@cop.ufl.edu
Gong
Yan
Y
Handberg
Eileen M
EM
Bavry
Anthony A
AA
Denardo
Scott J
SJ
Bakris
George L
GL
Pepine
Carl J
CJ
D000368:Aged; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001794:Blood Pressure; D015331:Cohort Studies; D003324:Coronary Artery Disease / Q000150:complications* / Q000401:mortality*; D048909:Diabetes Complications / Q000401:mortality*; D003920:Diabetes Mellitus; D005260:Female; D006801:Humans; D006973:Hypertension / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology; D016032:Randomized Controlled Trials as Topic; D012306:Risk; D020521:Stroke / Q000453:epidemiology; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
D000959:Antihypertensive Agents