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Coronary heart disease and antihypertensive treatment

Data from the EUROASPIRE Survey I, II and III clearly show that the prevalence of arterial hypertension (AH) in patients with coronary heart disease (CHD) is high, not changing during the time, being around 54-55%. AH is a major risk factor for CHD and both, systolic and diastolic blood pressure are strongly associated with coronary morbidity and mortality. Therapeutical intervention lowering blood pressure is associated with a decreased risk for major coronary events and death. Therefore, optimal antihypertensive treatment is crucial for CHD stability and prognosis. Possible clinical manifestations of CHD (different forms of angina, acute myocardial infarction, heart failure, arrhythmias, sudden cardiac death or silent ischemia) need different therapeutical approach in the optimal blood pressure management. According to ESH/ESC 2007 Guidelines for the management of AH, each of five main groups of antihypertensives and their possible combinations may be used, depending on CHD clinical presentation, some drugs having advantages in specific conditions. European 2007 Guidelines on cardiovascular disease prevention recommend secondary prevention of CHD summarized in the acronym BASIC: Beta-blocker, Aspirin, Statin, Inhibitor of ACE, and Control of risk factors, with the goal blood pressure under 130/80 mmHg (level of evidence A, class of recommendation I). Although there is a strong inverse correlation between blood pressure and coronary risk, because of a „J curve“ effect (i.e., increase in risk at a very low pressure) sudden fall of blood pressure to very low levels could be harmful. Beta-blockers (BB) and ACE inhibitors (ACE-I) are the two main groups of antihypertensives which should be used in CHD patients with associated AH. Multiple beneficial effects of BB on the ischemic heart are well known, with improvement in quality of life and survival. There are also some general unfavorable effects of BB, including adverse metabolic effects and elevated risk for new onset type 2 diabetes. As a group, BB have different pharmacological properties (cardioselectivity, impact on insulin sensitivity, lung function, erectile function, heart rate, peripheral vascular resistance). Optimal selection of BB should be individualized, based on patients clinical characteristics. ACE-I exert antiatherosclerotic action, stabilise the coronary plaque, prevent coronary events, LV dysfunction and overt heart failure, especially post MI. Such beneficial effects have been proven in many studies with pts of different age, LV function and clinical forms of CHD. ACE-I protect against CHD and calcium channel blockers (CCBs) protect against stroke even beyond their antihypertensive activity. CCBs have also multiple beneficial effects on the ischemic heart, and should be used in combination with BB and ACE-I, if needed (in effort, mixed or unstable angina, as well as in silent ischemia). In some situations CCBs are the optimal first choice, e.g. in vasospastic/variant, cold or microvascular angina. In acute MI CCBs must be avoided. There is a treatment gap between evidence and practice, only 40% of CHD pts with AH being well controlled. There is a need for action against therapeutic inertia, insisting on life style changes and prescription of antihypertensive drugs according to guidelines, once daily, with slow onset of action.

coronary heart disease; arterial hypertension; management

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