Importance of Blood Pressure Control in Hypertensive Patients With Coronary Heart Disease in Clinical Practice to Reduce the Risk of Stroke
To the Editor:
We wish to comment on the manuscript of Coca et al about which factors may influence the stroke risk among patients with coronary artery disease.1 For this purpose, data from the 22576 patients enrolled in the INternational VErapamil SR-trandolapril STudy (INVEST) were used. Interestingly, excellent blood pressure control was achieved, at 24 months, >70% of patients attained values <140/90 mmHg during 61835 patient-years of follow-up. At the study end, 377 patients had a stroke (6.1 strokes/1000 patient-years) and 28% of those patients had a fatal stroke. Increased age, black race, US residency, and history of prior myocardial infarction, smoking, stroke/transient ischemic attack, arrhythmia, diabetes, and coronary bypass surgery were associated with an increased risk of stroke. As expected, achieving a systolic blood pressure <140 mmHg and a diastolic blood pressure <90 mmHg was associated with a decreased risk of stroke. As authors remarked, these results strongly support the importance of reducing blood pressure to <140/90 mmHg for stroke prevention in patients with coronary artery disease.
Although information given by controlled randomized trials is very important, it is not always reliable to clinical practice. Clinical trials are somehow selective, and sometimes significant differences remain between randomized trials and the “real world” of clinical practice.2–4 Although there are several causes to explain this difference, the more strict follow-up, the more favorable clinical profile and the major motivation of the patients to take the medication may be potential reasons that result in a better blood pressure control in these studies.4
Because blood pressure control is crucial to decrease the stroke risk, especially in those populations at highest risk such as those patients with hypertension and coronary artery disease, it seems necessary to explore the real blood pressure control in clinical practice. For this reason, a recent survey was performed.5 In this study, a total of 2024 patients with hypertension and ischemic disease were included. 78.4% of the patients had dyslipidemia and 32.3% diabetes. Left ventricular hypertrophy was present in 49.0% of the patients, heart failure in 18.4%, periphery artery disease in 16.0%, renal impairment in 12.4% and stroke in 8.5%. Blood pressure control was achieved in 40.5% of patients. This highlights that in clinical practice, blood pressure control is far from those obtained in clinical trials, and as a result, cardiovascular events like stroke, are more frequent than those observed in randomized trials.
Although in the last years, blood pressure control rates have improved in Western countries, they are still far from optimal, especially in high-risk populations such as those with coronary artery disease in which blood pressure goals are more strict.6
In conclusion, these data show that there is a strong relationship between blood pressure control and the stroke risk, and secondly that it is necessary to perform studies that represents the “real world” of clinical practice to determine how the evidences obtained from clinical trials are translated into the daily management of the hypertensive population with ischemic heart disease.
Coca A, Messerli FH, Benetos A, Zhou Q, Champion A, Cooper-DeHoff RM, Pepine CJ. Predicting stroke risk in hypertensive patients with coronary artery disease: a report from the INVEST. Stroke. 2008; 39: 343–348.
Barrios V, Escobar C, Bertomeu V, Murga N, de Pablo C, Calderon A, Navarro A. Current situation of the risk factor control in the patients with hypertension and chronic ischemic heart disease attended in cardiologic outpatient clinics. The CINHTIA study. Rev Clin Esp. 2008; 400–404.
Ong KL, Cheung BM, Man YB, Lau CP, Lam KS. Prevalence, awareness, treatment, and control of hypertension among United States adults 1999–2004. Hypertension. 2007; 49: 69–75.