Maddox Thomas M, Ross Colleen, Tavel Heather M, Lyons Ella E, Tillquist Maggie, Ho P Michael, Rumsfeld John S, Margolis Karen L, O'Connor Patrick J, Selby Joe V, Magid David J
Cardiology Section, Denver VAMC/University of Colorado Denver, Denver, CO 80220, USA.
Circ Cardiovasc Qual Outcomes. 2010 Jul;3(4):347-57. doi: 10.1161/CIRCOUTCOMES.110.957308. Epub 2010 May 20.
Blood pressure (BP) control among coronary artery disease patients remains suboptimal in clinical practice, potentially due to gaps in treatment intensification and medication adherence. However, longitudinal studies evaluating these relationships and outcomes are limited.
We assessed BP trajectories among health maintenance organization patients with hypertension and incident coronary artery disease. BP trajectories were modeled over the year after coronary artery disease diagnosis, stratified by target BP goal. Treatment intensification (increase in BP therapies in the setting of an elevated BP), medication adherence (percentage of days covered with BP therapies), and outcomes (all-cause mortality, myocardial infarction, and revascularization) were evaluated in multivariable models: 9569 patients had a <140/90 mm Hg BP target and 12,861 had a <130/80 mm Hg BP target. Within each group, 4 trajectories were identified: good, borderline, improved, and poor control. After adjustment, increasing BP treatment intensity was significantly associated with better BP trajectories in both groups. Medication adherence had inconsistent effects. There were no significant differences in combined outcomes by BP trajectory, but among the diabetes and renal disease cohort, borderline control patients were less likely to have myocardial infarction (odds ratio, 0.61; 95% confidence interval, 0.40-0.93), and good control patients were less likely to have myocardial infarction (odds ratio, 0.53; 95% confidence interval, 0.34-0.84) or a revascularization procedure (odds ratio, 0.66; 95% confidence interval, 0.47-0.93) compared with poor control patients.
In this health maintenance organization population, treatment intensification but not medication adherence significantly affects BP trajectories in the year after coronary artery disease diagnosis. Better BP trajectories are associated with lower rates of myocardial infarction and revascularization.
在临床实践中，冠状动脉疾病患者的血压控制仍未达到最佳状态，这可能是由于治疗强化和药物依从性方面存在差距。然而，评估这些关系和结果的纵向研究有限。
我们评估了健康维护组织中患有高血压和新发冠状动脉疾病患者的血压轨迹。在冠状动脉疾病诊断后的一年中对血压轨迹进行建模，并按目标血压目标分层。在多变量模型中评估治疗强化（血压升高时增加血压治疗）、药物依从性（血压治疗覆盖天数的百分比）和结果（全因死亡率、心肌梗死和血运重建）：9569名患者的血压目标为<140/90 mmHg，12861名患者的血压目标为<130/80 mmHg。在每组中，确定了4种轨迹：良好、临界、改善和控制不佳。调整后，两组中增加血压治疗强度均与更好的血压轨迹显著相关。药物依从性的影响不一致。按血压轨迹划分的综合结果没有显著差异，但在糖尿病和肾病队列中，与控制不佳的患者相比，临界控制的患者发生心肌梗死的可能性较小（比值比，0.61；95%置信区间，0.40-0.93），良好控制的患者发生心肌梗死（比值比，0.53；95%置信区间，0.34-0.84）或血运重建手术（比值比，0.66；95%置信区间，0.47-0.93）的可能性较小。
在这个健康维护组织人群中，治疗强化而非药物依从性在冠状动脉疾病诊断后的一年中显著影响血压轨迹。更好的血压轨迹与较低的心肌梗死和血运重建发生率相关。
