title: Systolic and diastolic blood pressure changes in relation with myocardial infarction and stroke in patients with coronary artery disease.
abstract: Excessively high and low achieved blood pressure (BP) may be associated with a bad outcome in patients with coronary artery disease, the J curve phenomenon. The effect of BP changes from baseline in relation with the subsequent risk of stroke and myocardial infarction (MI) is unknown. Of the 25 620 patients randomized in the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) study, we selected 19 102 patients with coronary artery disease at baseline. BP at entry was 141/82 mm Hg, and its average decrease during follow-up was 7/6 mm Hg. BP entered the analysis as time-varying variable modeled with restricted cubic splines. After adjustment for several potential determinants of reverse causality, a change in BP from baseline by -34/-21 mm Hg (10th percentile) was associated with a lesser risk of stroke without any significant increase in the risk of MI. A rise in systolic/diastolic BP from baseline by 20/10 mm Hg (90th percentile) was associated with an increased risk of stroke, whereas the risk of MI increased with systolic BP and not with diastolic BP. In conclusion, in patients with coronary artery disease and initially free from congestive heart failure, a BP reduction from baseline over the examined BP range had little effect on the risk of MI and predicted a lower risk of stroke. An increase in systolic BP from baseline increased the risk of stroke and MI. The relationships of BP with risk were much steeper for stroke than for MI. A treatment-induced BP reduction over the explored range seems to be safe in patients with coronary artery disease.
  
  
  BACKGROUND
  http://www.clinicaltrials.gov. Unique identifier: NCT00153101.
authors.affiliation: From the Department of Medicine, Hospital of Assisi, Assisi, Italy (P.V.); Department of Medicine (G.R.) and Department of Cardiology and Cardiovascular Pathophysiology (F.A.), University Hospital of Perugia, Perugia, Italy; Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University 'Federico II', Naples, Italy (B.T.); Department of Health Sciences, University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Milano, Italy (G.M.); Department of Clinical Epidemiology and Biostatistics and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.P., P.G., K.T., S.Y.); and Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, United Kingdom (P.S.). verdec@tin.it.
authors.forename: Paolo
authors.initials: P
authors.lastname: Verdecchia
authors.affiliation: From the Department of Medicine, Hospital of Assisi, Assisi, Italy (P.V.); Department of Medicine (G.R.) and Department of Cardiology and Cardiovascular Pathophysiology (F.A.), University Hospital of Perugia, Perugia, Italy; Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University 'Federico II', Naples, Italy (B.T.); Department of Health Sciences, University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Milano, Italy (G.M.); Department of Clinical Epidemiology and Biostatistics and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.P., P.G., K.T., S.Y.); and Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, United Kingdom (P.S.).
authors.forename: Gianpaolo
authors.initials: G
authors.lastname: Reboldi
authors.affiliation: From the Department of Medicine, Hospital of Assisi, Assisi, Italy (P.V.); Department of Medicine (G.R.) and Department of Cardiology and Cardiovascular Pathophysiology (F.A.), University Hospital of Perugia, Perugia, Italy; Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University 'Federico II', Naples, Italy (B.T.); Department of Health Sciences, University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Milano, Italy (G.M.); Department of Clinical Epidemiology and Biostatistics and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.P., P.G., K.T., S.Y.); and Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, United Kingdom (P.S.).
authors.forename: Fabio
authors.initials: F
authors.lastname: Angeli
authors.affiliation: From the Department of Medicine, Hospital of Assisi, Assisi, Italy (P.V.); Department of Medicine (G.R.) and Department of Cardiology and Cardiovascular Pathophysiology (F.A.), University Hospital of Perugia, Perugia, Italy; Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University 'Federico II', Naples, Italy (B.T.); Department of Health Sciences, University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Milano, Italy (G.M.); Department of Clinical Epidemiology and Biostatistics and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.P., P.G., K.T., S.Y.); and Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, United Kingdom (P.S.).
authors.forename: Bruno
authors.initials: B
authors.lastname: Trimarco
authors.affiliation: From the Department of Medicine, Hospital of Assisi, Assisi, Italy (P.V.); Department of Medicine (G.R.) and Department of Cardiology and Cardiovascular Pathophysiology (F.A.), University Hospital of Perugia, Perugia, Italy; Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University 'Federico II', Naples, Italy (B.T.); Department of Health Sciences, University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Milano, Italy (G.M.); Department of Clinical Epidemiology and Biostatistics and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.P., P.G., K.T., S.Y.); and Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, United Kingdom (P.S.).
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Mancia
authors.affiliation: From the Department of Medicine, Hospital of Assisi, Assisi, Italy (P.V.); Department of Medicine (G.R.) and Department of Cardiology and Cardiovascular Pathophysiology (F.A.), University Hospital of Perugia, Perugia, Italy; Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University 'Federico II', Naples, Italy (B.T.); Department of Health Sciences, University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Milano, Italy (G.M.); Department of Clinical Epidemiology and Biostatistics and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.P., P.G., K.T., S.Y.); and Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, United Kingdom (P.S.).
authors.forename: Janice
authors.initials: J
authors.lastname: Pogue
authors.affiliation: From the Department of Medicine, Hospital of Assisi, Assisi, Italy (P.V.); Department of Medicine (G.R.) and Department of Cardiology and Cardiovascular Pathophysiology (F.A.), University Hospital of Perugia, Perugia, Italy; Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University 'Federico II', Naples, Italy (B.T.); Department of Health Sciences, University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Milano, Italy (G.M.); Department of Clinical Epidemiology and Biostatistics and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.P., P.G., K.T., S.Y.); and Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, United Kingdom (P.S.).
authors.forename: Peggy
authors.initials: P
authors.lastname: Gao
authors.affiliation: From the Department of Medicine, Hospital of Assisi, Assisi, Italy (P.V.); Department of Medicine (G.R.) and Department of Cardiology and Cardiovascular Pathophysiology (F.A.), University Hospital of Perugia, Perugia, Italy; Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University 'Federico II', Naples, Italy (B.T.); Department of Health Sciences, University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Milano, Italy (G.M.); Department of Clinical Epidemiology and Biostatistics and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.P., P.G., K.T., S.Y.); and Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, United Kingdom (P.S.).
authors.forename: Peter
authors.initials: P
authors.lastname: Sleight
authors.affiliation: From the Department of Medicine, Hospital of Assisi, Assisi, Italy (P.V.); Department of Medicine (G.R.) and Department of Cardiology and Cardiovascular Pathophysiology (F.A.), University Hospital of Perugia, Perugia, Italy; Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University 'Federico II', Naples, Italy (B.T.); Department of Health Sciences, University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Milano, Italy (G.M.); Department of Clinical Epidemiology and Biostatistics and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.P., P.G., K.T., S.Y.); and Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, United Kingdom (P.S.).
authors.forename: Koon
authors.initials: K
authors.lastname: Teo
authors.affiliation: From the Department of Medicine, Hospital of Assisi, Assisi, Italy (P.V.); Department of Medicine (G.R.) and Department of Cardiology and Cardiovascular Pathophysiology (F.A.), University Hospital of Perugia, Perugia, Italy; Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University 'Federico II', Naples, Italy (B.T.); Department of Health Sciences, University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Milano, Italy (G.M.); Department of Clinical Epidemiology and Biostatistics and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.P., P.G., K.T., S.Y.); and Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, United Kingdom (P.S.).
authors.forename: Salim
authors.initials: S
authors.lastname: Yusuf
mesh_terms: D000368:Aged; D047228:Angiotensin II Type 1 Receptor Blockers / Q000008:administration & dosage; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage; D001562:Benzimidazoles / Q000008:administration & dosage*; D001565:Benzoates / Q000008:administration & dosage*; D001794:Blood Pressure / Q000187:drug effects / Q000502:physiology*; D003324:Coronary Artery Disease / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology; D003971:Diastole; D004305:Dose-Response Relationship, Drug; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000209:etiology / Q000517:prevention & control*; D017257:Ramipril / Q000008:administration & dosage*; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D013599:Systole; D000077333:Telmisartan; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D001562:Benzimidazoles; D001565:Benzoates; D017257:Ramipril; D000077333:Telmisartan
keywords: blood pressure; coronary artery disease; myocardial infarction; prognosis; stroke