Tight Blood Pressure Control and Cardiovascular Outcomes Among Hypertensive Patients With Diabetes and Coronary Artery Disease
Open accessAbstract
CONTEXT: Hypertension guidelines advocate treating systolic blood pressure (BP) to less than 130 mm Hg for patients with diabetes mellitus; however, data are lacking for the growing population who also have coronary artery disease (CAD). OBJECTIVE: To determine the association of systolic BP control achieved and adverse cardiovascular outcomes in a cohort of patients with diabetes and CAD. DESIGN, SETTING, AND PATIENTS: Observational subgroup analysis of 6400 of the 22,576 participants in the International Verapamil SR-Trandolapril Study (INVEST). For this analysis, participants were at least 50 years old and had diabetes and CAD. Participants were recruited between September 1997 and December 2000 from 862 sites in 14 countries and were followed up through March 2003 with an extended follow-up through August 2008 through the National Death Index for US participants. INTERVENTION: Patients received first-line treatment of either a calcium antagonist or beta-blocker followed by angiotensin-converting enzyme inhibitor, a diuretic, or both to achieve systolic BP of less than 130 and diastolic BP of less than 85 mm Hg. Patients were categorized as having tight control if they could maintain their systolic BP at less than 130 mm Hg; usual control if it ranged from 130 mm Hg to less than 140 mm Hg; and uncontrolled if it was 140 mm Hg or higher. MAIN OUTCOME MEASURES: Adverse cardiovascular outcomes, including the primary outcomes which was the first occurrence of all-cause death, nonfatal myocardial infarction, or nonfatal stroke. RESULTS: During 16,893 patient-years of follow-up, 286 patients (12.7%) who maintained tight control, 249 (12.6%) who had usual control, and 431 (19.8%) who had uncontrolled systolic BP experienced a primary outcome event. Patients in the usual-control group had a cardiovascular event rate of 12.6% vs a 19.8% event rate for those in the uncontrolled group (adjusted hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.25-1.71; P < .001). However, little difference existed between those with usual control and those with tight control. Their respective event rates were 12.6% vs 12.7% (adjusted HR, 1.11; 95% CI, 0.93-1.32; P = .24). The all-cause mortality rate was 11.0% in the tight-control group vs 10.2% in the usual-control group (adjusted HR, 1.20; 95% CI, 0.99-1.45; P = .06); however, when extended follow-up was included, risk of all-cause mortality was 22.8% in the tight control vs 21.8% in the usual control group (adjusted HR, 1.15; 95% CI, 1.01-1.32; P = .04). CONCLUSION: Tight control of systolic BP among patients with diabetes and CAD was not associated with improved cardiovascular outcomes compared with usual control. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00133692.
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INVEST, CLARIFY, ONTARGET, and TRANSCEND found that systolic pressure below 120 mm Hg and diastolic pressure below 70 mm Hg were linked to adverse cardiovascular outcomes, except for lower stroke risk at lower pressures.
“systolic blood pressure of <120 mm Hg and diastolic blood pressure <70 mm Hg were associated with adverse cardiovascular outcomes except for reduced risk of stroke in those achieving lower blood pressure values.66–68”
From Clinical management of stable coronary artery disease in patients with type 2 diabetes mellitus: a scientific statement from the American Heart Association (2020) · cites this paper as [66]
Later trials of lowering blood pressure below 130 mm Hg in type 2 diabetes and hypertension found no meaningful reduction in coronary events, though stroke risk fell.
“However, subsequent trials that specifically examined the role of a blood pressure lowering strategy to <130 mm Hg in patients with T2DM and hypertension found no substantive benefit of intensive blood pressure control in reducing the risk of coronary events, although there was evidence for decreased risk of stroke.5,66–69”
From Clinical management of stable coronary artery disease in patients with type 2 diabetes mellitus: a scientific statement from the American Heart Association (2020) · cites this paper as [66]
All patients with type 2 diabetes and coronary disease benefit from blood pressure below 140/90 mm Hg.
“As such, while all patients with T2DM and CAD certainly benefit from a blood pressure of <140/90 mm Hg,5,63–66,76”
From Clinical management of stable coronary artery disease in patients with type 2 diabetes mellitus: a scientific statement from the American Heart Association (2020) · cites this paper as [66]
Excessive blood pressure lowering in coronary disease, especially with left ventricular hypertrophy or dysfunction, may raise myocardial infarction risk by reducing coronary perfusion pressure across diseased segments when autoregulation is impaired.
“Excessive blood pressure lowering in patients with concomitant CAD (especially in the presence of left ventricular hypertrophy or dysfunction) can potentially increase the risk of myocardial infarction due to a drop in coronary perfusion pressures across the diseased segments of the coronary arteries secondary to impairment of coronary autoregulation.64–68”
From Clinical management of stable coronary artery disease in patients with type 2 diabetes mellitus: a scientific statement from the American Heart Association (2020) · cites this paper as [66]
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- Authors
- Cooper-DeHoff, R. M., Gong, Y., Handberg, E. M., Bavry, A. A., Denardo, S. J., Bakris, G. L., & Pepine, C. J.
- Affiliations
- University of Florida Health (US)
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2010-07-07
- Volume
- 304
- Issue
- 1
- Pages
- 61
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- PMC
- PMC3008411
- OpenAlex
- W2048695535
- Cited by
- 651
- References
- 33
- Citations by year
- 2026: 3 · 2025: 8 · 2024: 12 · 2023: 10 · 2022: 19 · 2021: 17 · 2020: 24 · 2019: 26 · 2018: 29 · 2017: 35 · 2016: 44 · 2015: 53 · 2014: 67 · 2013: 84 · 2012: 89
- FWCI
- 66.28
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- U.S. Public Health Service (U0IGM074492)
- National Heart, Lung, and Blood Institute (K23HL086558)
- National Institute of General Medical Sciences (U01GM074492)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart rate and cardiovascular health
- Keywords
- tight blood pressure control, systolic blood pressure, hypertension, diabetes mellitus, coronary artery disease, cardiovascular outcomes, all-cause mortality, myocardial infarction, stroke, antihypertensive therapy, ACE inhibitors, calcium channel blockers, beta-blockers, diuretics, INVEST trial, older adults, cardiovascular risk stratification
- MeSH terms
- Aged, Antihypertensive Agents, Blood Pressure, Coronary Artery Disease, Diabetes Mellitus, Female, Humans, Hypertension, Male, Middle Aged, Myocardial Infarction, Risk, United States, Cohort Studies, Randomized Controlled Trials as Topic, Treatment Outcome, Stroke, Diabetes Complications
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