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Management of arterial hypertension in patients with peripheral arterial disease
Pavel Poredoš1, Dimitri P Mikhailidis2,3, Kosmas I Paraskevas4
1Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia.
Insights
Hypertension significantly increases risks for peripheral arterial disease (PAD) and cardiovascular events. Optimal blood pressure targets for PAD patients may differ, as very low systolic blood pressure (<120 mmHg) can worsen outcomes.
Area of Science:
- Cardiovascular Medicine
- Vascular Biology
- Hypertension Research
Background:
- Hypertension is a primary risk factor for peripheral arterial atherosclerotic disease (PAD), negatively impacting arterial wall structure and function.
- Elevated blood pressure contributes to endothelial dysfunction, smooth muscle cell hyperplasia, and arterial remodeling, increasing peripheral resistance and atherosclerosis.
- Hypertension, especially with dyslipidemia, accelerates atherosclerosis in various vascular beds, notably the lower extremities.
Purpose of the Study:
- To examine the complex relationship between hypertension management and outcomes in patients with peripheral arterial disease (PAD).
- To evaluate the impact of specific blood pressure targets on cardiovascular and limb-related events in PAD patients.
- To assess the role of different antihypertensive drug classes in managing hypertension within the PAD population.
Main Methods:
- Review of existing literature and clinical guidelines on hypertension management in PAD.
- Analysis of the association between systolic blood pressure (SBP) levels and cardiovascular (CV) events in PAD patients.
- Consideration of the effects of antihypertensive medications, including ACE inhibitors, on perfusion and outcomes in PAD.
Main Results:
- Hypertension is linked to increased risk of CV events and PAD progression.
- A J-shape relationship exists between SBP and primary outcomes, indicating that SBP <120 mmHg may be associated with adverse events.
- ACE inhibitors may offer additional benefits for leg perfusion in PAD patients, including those with critical limb ischemia.
Conclusions:
- Treatment of hypertension is crucial for patients with PAD to reduce cardiovascular event risk.
- However, achieving very low blood pressure targets (SBP <120 mmHg, DBP <70 mmHg) may lead to adverse limb and cardiovascular outcomes.
- PAD patients might require individualized blood pressure targets distinct from those without PAD to optimize overall health and limb salvage.
Abstract:
Hypertension is a major risk factor for peripheral arterial atherosclerotic disease (PAD). Hypertension deteriorates arterial wall function and the morphology of all layers of arteries. Endothelial cell injury enhances permeability and promotes migration of cholesterol and monocytes into the vessel wall. Increased blood pressure (BP) through hyperplasia of smooth muscle cells initiates remodeling of the arterial wall that increases peripheral resistance. Further, hypertension, particularly in patients with dyslipidemia, provokes atherosclerosis in different vascular territories, including the lower legs. Guidelines recommend treatment of hypertension in patients with PAD to reach the target BP of <130/80 mmHg. However, systolic BP (SBP) <120 mmHg may worsen oxygen delivery to the diseased leg and is related to a higher rate of cardiovascular (CV) events. Therefore, there is a J-shape relationship between SBP and the rate of primary outcomes. Any class of antihypertensive drugs, including beta-blockers, can be used for the treatment of hypertension in patients with PAD. Angiotensin converting enzyme (ACE) inhibitors may have some additional benefit over other antihypertensive drugs including improvement of perfusion of the diseased leg and are recommended even in patients with critical limb ischemia. In conclusion: hypertensive patients with PAD are at increased risk for CV events and treatment of raised BP is indicated, but SBP <120 mmHg and DBP <70 mmHg may contribute to adverse limb outcomes and other CV events. Consequently, PAD patients may require a different BP target than those without PAD.
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