Blood pressure control in the year following coronary events

https://doi.org/10.1016/j.ijcard.2007.08.042Get rights and content

Abstract

Background

Blood pressure control is often insufficient in secondary prevention. The objective of the present study was to determine predictors for long-term elevated blood pressure (BP) in patients after coronary events.

Methods

Patients were included at admission to inpatient cardiac rehabilitation. A total of 18 cardiac rehabilitation centers in Germany participated. Indications for admission were myocardial infarction (MI), coronary artery bypass grafting (CABG), or percutaneous transluminal coronary angioplasty (PTCA). The duration of follow-up was 12 months. Risk factors, medication, and clinical events were assessed from patients and their physicians.

Results

A consecutive sample of 1907 men (mean age 60 ± 10 years) and 534 women (mean age 65 ± 10 years) was admitted; the 12-month follow-up rate was 85%. Of all patients, 38% had a BP ≥ 140 and/or ≥ 90 mmHg at admission to the rehabilitation center compared to 48% at the 12-month follow-up. Patients with diabetes were less likely to achieve BP < 140/90 mmHg compared to patients without diabetes (43% vs. 56%; P < 0.001). In multivariable analyses, significant predictors for elevated BP after 12 months were baseline BP ≥ 140/90 mmHg (RR 2.5; 95% CI 1.7, 3.7), diabetes (RR 2.2; 95% CI 1.4, 3.5), and indication for admission (MI vs. CABG RR 0.6; 95% CI 0.4, 1.0, and PTCA vs. CABG RR 0.5; 95% CI 0.2, 1.0).

Conclusions

Long-term blood pressure control is not satisfactory in about half of the patients following coronary events. Particularly, patients with diabetes appear to be at risk for elevated blood pressure.

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.

References (35)

  • G. De Backer et al.

    European guidelines on cardiovascular disease prevention in clinical practice. Third Joint Task Force of European and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of eight societies and by invited experts)

    Arch Mal Coeur Vaiss

    (2004)
  • R.M. Conroy et al.

    Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project

    Eur Heart J

    (2003)
  • B.M. Psaty et al.

    Health outcomes associated with various antihypertensive therapies used as first-line agents: a network meta-analysis

    JAMA

    (2003)
  • F. Turnbull

    Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials

    Lancet

    (2003)
  • P. Rashid et al.

    Blood pressure reduction and secondary prevention of stroke and other vascular events: a systematic review

    Stroke

    (2003)
  • S. Vijan et al.

    Treatment of hypertension in type 2 diabetes mellitus: blood pressure goals, choice of agents, and setting priorities in diabetes care

    Ann Intern Med

    (2003)
  • Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries. EUROASPIRE I and II Group. European Action on Secondary Prevention by Intervention to Reduce Events

    Lancet

    (2001)
  • Cited by (0)

    View full text