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On-Treatment Diastolic Blood Pressure and Prognosis in Systolic Hypertension
Robert H. Fagard, MD;
Jan A. Staessen, MD;
Lutgarde Thijs, MSc;
Hilde Celis, MD;
Christopher J. Bulpitt, MD;
Peter W. de Leeuw, MD;
Gastone Leonetti, MD;
Jaakko Tuomilehto, MD;
Yair Yodfat, MD
Arch Intern Med. 2007;167(17):1884-1891.
Background It has been suggested that low diastolic blood pressure (BP) while receiving antihypertensive treatment (hereinafter called on-treatment BP) is harmful in older patients with systolic hypertension. We examined the association between on-treatment diastolic BP, mortality, and cardiovascular events in the prospective placebo-controlled Systolic Hypertension in Europe Trial.
Methods Elderly patients with systolic hypertension were randomized into the double-blind first phase of the trial, after which all patients received active study drugs (phase 2). We assessed the relationship between outcome and on-treatment diastolic BP by use of multivariate Cox regression analysis during receipt of placebo (phase 1) and during active treatment (phases 1 and 2).
Results Rates of noncardiovascular mortality, cardiovascular mortality, and cardiovascular events were 11.1, 12.0, and 29.4, respectively, per 1000 patient-years with active treatment (n = 2358) and 11.9, 12.6, and 39.0, respectively, with placebo (n = 2225). Noncardiovascular mortality, but not cardiovascular mortality, increased with low diastolic BP with active treatment (P < .005) and with placebo (P < .05); for example, hazard ratios for lower diastolic BP, that is, 65 to 60 mm Hg, were, respectively, 1.15 (95% confidence interval, 1.00-1.31) and 1.28 (95% confidence interval, 1.03-1.59). Low diastolic BP with active treatment was associated with increased risk of cardiovascular events, but only in patients with coronary heart disease at baseline (P < .02; hazard ratio for BP 65-60 mm Hg, 1.17; 95% confidence interval, 0.98-1.38).
Conclusions These findings support the hypothesis that antihypertensive treatment can be intensified to prevent cardiovascular events when systolic BP is not under control in older patients with systolic hypertension, at least until diastolic BP reaches 55 mm Hg. However, a prudent approach is warranted in patients with concomitant coronary heart disease, in whom diastolic BP should probably not be lowered to less than 70 mm Hg.
Author Affiliations: Hypertension and Cardiovascular Rehabilitation Unit, University of Leuven, Leuven, Belgium (Drs Fagard, Staessen, and Celis and Ms Thijs); Imperial College, Hammersmith Hospital, London, United Kingdom (Dr Bulpitt); University of Maastricht, Maastricht, the Netherlands (Dr de Leeuw); Istituto Auxologico Italiano, Ospedale San Luca, Milan, Italy (Dr Leonetti); National Public Health Institute and the University of Helsinki, Helsinki, Finland, and South Ostrobothnia Central Hospital, Seinäjoki, Finland (Dr Tuomilehto); and Department of Family Medicine, Hadassah Medical School, Hebrew University of Jerusalem, Jerusalem, Israel (Dr Yodfat).
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Cleveland Clinic Journal of Medicine 2008;75:168-169.
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