Coronary morbidity and mortality, pre-existing silent coronary artery disease, and mild hypertension
B F O'Kelly1, B M Massie, J F Tubau
1University of California, San Francisco.
Insights
Hypertension contributes to atherosclerosis, but trials for mild hypertension showed inconsistent cardiac event reduction. This may be due to trial limitations and pre-existing advanced coronary artery disease in participants.
Area of Science:
- Cardiovascular Medicine
- Hypertension Research
- Atherosclerosis Studies
Background:
- Hypertension is a known promoter of atherosclerosis development and progression.
- Major clinical trials on mild hypertension treatment have yielded inconsistent results regarding cardiac event reduction.
- Understanding the interplay between hypertension, atherosclerosis, and myocardial ischemia is crucial.
Purpose of the Study:
- To review major antihypertensive therapy trials for mild hypertension.
- To analyze pathophysiologic relationships among hypertension, atherosclerosis, and myocardial ischemia.
- To re-evaluate the efficacy of antihypertensive therapy in light of trial limitations and patient characteristics.
Main Methods:
- Review of existing experimental findings in animals and epidemiologic studies in humans.
- Analysis of data from major clinical trials investigating antihypertensive therapy for mild hypertension.
- Examination of autopsy and epidemiologic data to assess pre-existing coronary artery disease in trial participants.
Main Results:
- Trial power was limited by factors including size, entry criteria, and duration.
- A significant proportion of participants likely had advanced coronary artery disease at trial entry.
- Antihypertensive therapy alone did not consistently prevent cardiac events in short-term trials.
Conclusions:
- The failure of antihypertensive therapy to prevent cardiac events in short-term trials may be attributed to trial design and participant selection.
- Patients with pre-existing advanced coronary artery disease may not benefit from short-term antihypertensive therapy alone.
- These findings do not negate the potential value of antihypertensive therapy as a long-term strategy for cardiovascular event prevention.
Abstract:
Experimental findings in animals and epidemiologic studies in humans provide strong evidence that hypertension promotes the onset and progression of atherosclerosis. However, effective antihypertensive therapy has not consistently reduced the incidence of cardiac events in the major trials of treatment for mild hypertension. In reviewing these trials and the recent data on the pathophysiologic interrelationships among hypertension, atherosclerosis, and myocardial ischemia, two factors stand out: First, the power of these trials to produce a positive result was limited because of their size, entry criteria, duration, and other considerations; second, autopsy and epidemiologic data suggest that some patients in these trials probably had advanced coronary artery disease at the time of entry. Because these patients probably developed symptomatic coronary artery disease by virtue of this pre-existing disease, the failure of antihypertensive therapy alone to prevent cardiac events in trials of relatively short duration should not be construed as evidence against its value as a long-term therapy.
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