Blood pressure control in the year following coronary events
Introduction
Current guidelines recommend the reduction of blood pressure levels below 140/90 mmHg in all patients at high risk [1], [2], [3]. High-risk patients are defined either as patients at high risk of a cardiovascular event or as patients who already have a history of coronary heart disease and/or stroke in the European guidelines. A risk of cardiovascular death of more than 5% in the next 10 years is defined as a high risk according to the risk estimations based on the Systematic Coronary Risk Evaluation (SCORE) project [4], [5]. In patients with diabetes, the recommended blood pressure level is even below 130/80 mmHg. These recommendations are based on several meta-analyses and large randomised controlled trials showing that the effective reduction in both systolic and diastolic blood pressure significantly lowers cardiovascular morbidity and mortality [6], [7], [8], [9], [10], [11]. Although there is no consensus on the most effective antihypertensive drug or combination of drugs to use, the achievement of the target blood pressure levels is a major goal in the prevention of cardiovascular diseases.
However, a number of studies have shown that there is a clear gap between recommendations and their translation into daily practice [12], [13], [14]. In secondary prevention following coronary events, for example, the EUROASPIRE studies I and II found that the proportion of patients with elevated blood pressure levels (≥ 140/90 mmHg) was 55% and 54% in 1995–96 and 1999–2000, respectively [12]. These studies have been based on previous guidelines, as a time interval needs to be taken into account between the publication and distribution of a guideline and its implementation into routine care by the medical community [15], [16], [17]. However, current guidelines are similar to previous guidelines, which also recommend blood pressure levels below 140/90 mmHg for all patients and < 130/80 mmHg or 130/85 mmHg for patients with diabetes. This is based on the publication of several large randomised controlled trials showing that aggressive lowering of blood pressure levels is even more important in patients with diabetes [18], [19], [20]. Overall, it is important to identify those patients at particular risk for elevated blood pressure in the long-term follow-up. The objective of the present study was, therefore, to assess blood pressure control in the year following coronary events, with focus on patients with diabetes, and to determine early predictors for elevated blood pressure.
Section snippets
Design and setting
The Post Infarction Care (PIN) Study was designed as a prospective multi-centre study, which examined recurrent clinical events, cardiac risk factors, employment status, and medication after inpatient cardiac rehabilitation [21], [22], [23]. The follow-up period was 12 months. The design of the study and results as to the occurrence of clinical events including cardiovascular death, myocardial infarction, revascularisation, and angina pectoris and/or congestive heart failure with
Study population
Between January and July 1997, a total of 2441 patients were eligible for the PIN study and consented to participate. 92% (n = 2233) of the patients returned the questionnaire after 6 months and 85% (n = 2069) after 12 months. We contacted general practitioners to get additional information about the patients included in the study after 12 months; the response rate was 63% (n = 1536). Of all patients, 78% were men with a mean age of 60 ± 10 years, and 22% women with a mean age of 65 ± 10 years. A history
Discussion
In about half of the patients, the recommended blood pressure levels below 140/90 mmHg following coronary events are not achieved. Patients with diabetes, lower LDL cholesterol levels, as well as patients with an already elevated blood pressure at baseline are particularly at risk for elevated blood pressure at follow-up. In patients with diabetes, the gap between recommendations of guidelines and usual care is even larger with about only one tenth of diabetic patients achieving the recommended
Conclusion
Long-term blood pressure control following coronary events is not sufficient in about half of the patients. It is, therefore, important to identify those patients particularly at risk for elevated blood pressure in the long term. Especially patients with diabetes appear to be at risk for increased blood pressure levels at follow-up. Potential explanations range from physiological differences between patients with and without diabetes in the context of the metabolic syndrome to differences in
Acknowledgements
We would like to thank all the patients, the physicians of the participating rehabilitation centers as well as the general practitioners who contributed to the study. The steering committee included Völler H, Willich SN, Gohlke H, Hahmann H, Kleber FX, Krobot K, and Bestehorn K. We would also like to thank Merck, Sharp & Dohme for the unconditional funding of the study.
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