Relationships Between Components of Blood Pressure and Cardiovascular Events in Patients with Stable Coronary Artery Disease and Hypertension

Emmanuelle Vidal-Petiot; Nicola Greenlaw; Ian Ford; Roberto Ferrari; Kim M Fox; Jean-Claude Tardif; Michal Tendera; Alexander Parkhomenko; Deepak L Bhatt; P Gabriel Steg

doi:10.1161/HYPERTENSIONAHA.117.10204

Relationships Between Components of Blood Pressure and Cardiovascular Events in Patients with Stable Coronary Artery Disease and Hypertension

Hypertension. 2018 Jan;71(1):168-176. doi: 10.1161/HYPERTENSIONAHA.117.10204. Epub 2017 Oct 30.

Affiliations

¹ From the Cardiology and Physiology Departments, Département Hospitalo-Universitaire FIRE, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat and Paris Diderot University, Sorbonne Paris Cité, France (E.V.-P., P.G.S.); INSERM U1149, Centre de Recherche sur l'Inflammation, Paris, France (E.V.-P.); Robertson Centre for Biostatistics, University of Glasgow, United Kingdom (N.G., I.F.); Centro Cardiologico Universitario di Ferrara, University of Ferrara, and Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy (R.F.); National Heart and Lung Institute, Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, United Kingdom (K.M.F., P.G.S.); Department of Medicine, Montreal Heart Institute, Université de Montreal, Canada (J.-C.T.); Medical University of Silesia, School of Medicine in Katowice, Department of Cardiology and Structural Heart Disease, Poland (M.T.); Emergency Cardiology Department, Institute of Cardiology, Kiev, Ukraine (A.P.); Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and French Alliance for Cardiovascular Trials, an F-CRIN network, INSERM U1148, Laboratory for Vascular Translational Science, Paris, France (P.G.S.).
² From the Cardiology and Physiology Departments, Département Hospitalo-Universitaire FIRE, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat and Paris Diderot University, Sorbonne Paris Cité, France (E.V.-P., P.G.S.); INSERM U1149, Centre de Recherche sur l'Inflammation, Paris, France (E.V.-P.); Robertson Centre for Biostatistics, University of Glasgow, United Kingdom (N.G., I.F.); Centro Cardiologico Universitario di Ferrara, University of Ferrara, and Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy (R.F.); National Heart and Lung Institute, Imperial College, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, United Kingdom (K.M.F., P.G.S.); Department of Medicine, Montreal Heart Institute, Université de Montreal, Canada (J.-C.T.); Medical University of Silesia, School of Medicine in Katowice, Department of Cardiology and Structural Heart Disease, Poland (M.T.); Emergency Cardiology Department, Institute of Cardiology, Kiev, Ukraine (A.P.); Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and French Alliance for Cardiovascular Trials, an F-CRIN network, INSERM U1148, Laboratory for Vascular Translational Science, Paris, France (P.G.S.). gabriel.steg@aphp.fr.

PMID: 29084876
DOI: 10.1161/HYPERTENSIONAHA.117.10204

Abstract

Observational studies have shown a J-shaped relationship between diastolic blood pressure (BP) and cardiovascular events in hypertensive patients with coronary artery disease. We investigated whether the increased risk associated with low diastolic BP reflects elevated pulse pressure (PP). In 22 672 hypertensive patients with coronary artery disease from the CLARIFY registry (Prospective Observational Longitudinal Registry of Patients With Stable Coronary Artery Disease), followed for a median of 5.0 years, BP was measured annually and averaged. The relationships between PP and diastolic BP, alone or combined, and the primary composite outcome (cardiovascular death or myocardial infarction) were analyzed using multivariable Cox proportional hazards models. Adjusted hazard ratios for the primary outcome were 1.62 (95% confidence interval [CI], 1.40-1.87), 1.00 (ref), 1.07 (95% CI, 0.94-1.21), 1.54 (95% CI, 1.32-1.79), and 2.34 (95% CI, 1.95-2.81) for PP<45, 45 to 54 (reference), 55 to 64, 65 to 74, and ≥75 mm Hg, respectively, and 1.50 (95% CI, 1.31-1.72), 1.00 (reference), and 1.58 (95% CI, 1.42-1.77) for diastolic BPs of <70, 70 to 79 (ref), and ≥80 mm Hg, respectively. In a cross-classification analysis between diastolic BP and PP, the relationship between diastolic BP and the primary outcome remained J-shaped when the analysis was restricted to patients with the lowest-risk PP (45-64 mm Hg), with adjusted hazard ratios of 1.53 (95% CI, 1.27-1.83), 1.00 (ref), and 1.54 (95% CI, 1.34-1.75) in the <70, 70 to 79 (reference), and ≥80 mm Hg subgroups, respectively. The J-shaped relationship between diastolic BP and cardiovascular events in hypertensive patients with coronary artery disease persists in patients within the lowest-risk PP range and is therefore unlikely to be solely the consequence of an increased PP reflecting advanced vascular disease.

Clinical trial registration: URL: http://www.clarify-registry.com. Unique identifier: ISRCTN43070564.

Keywords: blood pressure; coronary artery disease; hypertension; myocardial infarction; proportional hazards models.

Publication types

Multicenter Study
Observational Study

MeSH terms

Aged
Blood Pressure / physiology*
Coronary Artery Disease* / complications
Coronary Artery Disease* / epidemiology
Coronary Artery Disease* / physiopathology
Diastole / physiology
Female
Humans
Hypertension* / complications
Hypertension* / diagnosis
Hypertension* / epidemiology
Hypertension* / physiopathology
Male
Middle Aged
Mortality
Myocardial Infarction* / epidemiology
Myocardial Infarction* / mortality
Outcome and Process Assessment, Health Care
Proportional Hazards Models
Registries / statistics & numerical data
Risk Factors
Stroke* / epidemiology
Stroke* / mortality

Associated data

ISRCTN/ISRCTN43070564