Treatment of hypertension in peripheral arterial disease

Peripheral arterial disease (PAD) causes considerable morbidity and mortality. Hypertension is a risk factor for PAD. Therefore, treatment for hypertension must be compatible with the symptoms of PAD. Controversy regarding the effects of beta blockade for hypertension in patients with PAD has led many physicians to stop prescribing beta-blockers. Little is known about the effects of other classes of anti-hypertensive drugs in the presence of PAD.

To determine the effects of anti-hypertensive drugs on the: cardiovascular events and death in patients with hypertension and PAD; symptoms of claudication and critical leg ischaemia; progression of PAD, and revascularisation, or amputations.

Trials were sought via the Specialised Register of the Cochrane Peripheral Vascular Diseases Group (last searched July 2003), the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 2, 2003), and the NHS Database of Abstracts of Reviews of Effectiveness (DARE) (last searched August 2002). There were no language restrictions. Abstracts of cardiology meetings were studied. Reference lists of papers were also examined.

Randomised controlled trials of at least one anti-hypertensive treatment against placebo, or two anti-hypertensive medications against each other, with interventions lasting at least one month. Trials had to include patients with symptomatic PAD. Trials of poor quality and execution were excluded, as were cross-over trials.

Data were extracted by one reviewer and checked by the other. Eligible studies were excluded when presentation prevented adequate extraction of data, and enquiries to authors did not yield the raw data.

Two studies were included in the review. In one trial using perindopril in small numbers of patients with PAD, there was a marginal increase in claudication distance (weighted mean difference (WMD) 8.0, 95% confidence interval (CI) -30.66 to 46.66), but no change in ankle brachial pressure index (ABPI), (WMD 0, 95% CI -0.14 to 0.14), and a reduction in walking distance (WMD -46, 95 % CI -169.24 to 77.24). In patients undergoing angioplasty, a second trial suggested that the calcium antagonist verapamil reduced restenosis, although this was not reflected in the maintenance of a high ABPI.

The evidence for various anti-hypertensive drug classes in PAD is poor, so that it is unknown whether significant benefit or risk accrues from their use. In view of this, no definite recommendations on use or avoidance can be made from the available data.