The broadening landscape for hypertension management

Overview of the studies that have provided evidence that in patients at high-risk (i.e., renal disease, diabetes, coronary artery disease, or cerebrovascular disease) cardiovascular protection is greater if: 1) BP is more aggressively reduced and target values are set at less than 130/80 mm Hg; and 2) antihypertensive drug treatment is started at BP values below 140/90 mm Hg. ABCD, Alternans Before Cardioverter Defibrillator Trial; ADVANCE, Action in Diabetes and Vascular Disease Trial; BP, blood pressure; CAD, coronary artery disease; CAMELOT, Comparison of Amlodipine vs. Enalapril to Limit Occurrences of Thrombosis Trial; EUROPA, European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease; HOPE, Heart Outcomes Prevention Evaluation trial; HOT, Hypertension Optimal Treatment Study; IDNT, Irbesartan Diabetic Nephropathy Trial; INVEST, International Verapamil-Trandolapril Study; PROGRESS, Perindopril Protection against Recurrent Stroke Study; TIA, transient ischemic attack; UKPDS, United Kingdom Prospective Diabetes Study.

Reductions in relative risk of stroke of major cardiovascular events achieved with antihypertensive therapy in hypertensive and nonhypertensive patients in the PROGRESS Trial. CI, confidence interval; PROGRESS, Perindopril Protection against Recurrent Stroke Study Trial. Reprinted with permission from PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischemic attack. Lancet 2001;358:1033–41.⁷

Kaplan-Meyer curves for cardiovascular mortality over an 11-year follow-up in the subjects of the PAMELA Study in whom office, home, and 24-hour mean BP were all normal or one, two, or three BPs were elevated (regardless of whether the elevation involved clinic, home, or ambulatory values). Values separating office, home, and ambulatory BP normality from elevation were 140/90 mm Hg, 132/83 mm Hg, and 125/79 mm Hg, respectively. BP, blood pressure; PAMELA, Pressioni Arteriose Monitorate e Loro Associazioni Study.

Effects on cardiovascular morbid or fatal events of trials comparing different antihypertensive drugs. ACE-I, angiotensin-converting enzyme inhibitor; ALLHAT, Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial; ANBP2, Australian National Blood Pressure Study Group; ARB, angiotensin receptor blocker; ASCOT, Anglo-Scandinavian Cardiac Outcomes Trial; BB, beta-blockers; CA, calcium antagonists; CAPPP, Captopril Prevention Project; CCB, calcium-channel blocker; CHD, coronary heart disease; CI, confidence interval; CONV, conventional treatment; CVD, cardiovascular disease; D, diuretic treatment; HAPPHY, Heart Attack Primary Prevention in Hypertension Trial; IPPPSH, International Prospective Primary Prevention Study in Hypertension; INSIGHT, International Nifedipine GITS Study: Intervention as a Goal in Hypertension Treatment; INVEST, International Verapamil-Trandolapril Study; LIFE, Losartan Intervention For Endpoint reduction in hypertension Study; MOSES, MOrbidity and mortality after Stroke, Eprosartan compared with nitrendipine for Secondary prevention; NORDIL, Nordic Diltiazem Study; SCOPE, Study on COgnition and Prognosis in the Elderly; STOP2, Stent vs. Thrombolysis for Occluded Coronary Arteries in Patients With Acute Myocardial Infarction 2 Study; VALUE, Valsartan Antihypertensive Long-Term Use Evaluation Study. Reproduced with permission from Mancia G. Role of outcome trials in providing information on antihypertensive treatment: importance and limitations. Am J Hypertens 2006;19:1–7.²⁰

Comparison of “new” and “old” antihypertensive agents for the outcome of new-onset diabetes. ACEI, angiotensin-converting enzyme inhibitor; ALPINE, Antihypertensive treatment and Lipid Profile In a North Sweden Efficacy evaluation; other abbreviations as in Figure 4. Reproduced with permission from Mancia G, Grassi G, Zanchetti A. New-onset diabetes and antihypertensive drugs. J Hypertens 2006;24:3–10.²⁴