University of Florida College of Medicine, Gainesville, FL, USA.
Am J Cardiol. 2010 Aug 15;106(4):498-503. doi: 10.1016/j.amjcard.2010.03.056.
The optimal blood pressure (BP) to prevent major adverse outcomes (death, myocardial infarction, and stroke) for patients with hypertension and coronary artery disease who have undergone previous revascularization is unknown but might be influenced by the type of revascularization procedure. We analyzed data from the INternational VErapamil SR-Trandolapril STudy, focusing on the relation between BP and the outcomes of 6,166 previously revascularized patients, using the 16,410 nonrevascularized patients as a reference group. The previous revascularization strategy consisted of coronary artery bypass grafting (CABG, 45.2%), percutaneous coronary intervention (PCI, 42.1%), or both (CABG+PCI, 12.8%). Patients who had undergone both CABG+PCI and CABG-only had a greater adverse outcome risk (adjusted hazard ratio 1.27% and 1.20%, 95% confidence interval 1.06 to 1.53 and 1.07 to 1.35, respectively). The risk was similar for PCI-only patients (adjusted hazard ratio 1.04, 95% confidence interval 0.92 to 1.19). The relations between the adjusted hazard ratio and on-treatment BP appeared J-shaped for each revascularization strategy, accentuated for PCI and diastolic BP (DBP), but excepting CABG only and DBP for which the relation was linear and positive. In conclusion, major adverse outcomes were more frequent in patients with coronary artery disease who had undergone previous CABG, with or without PCI, compared to those with previous PCI only. This likely reflected more severe vascular disease. The relation to systolic BP was J-shaped for each strategy. Among those patients with previous CABG only, the linear relation with DBP suggested that more complete revascularization might attenuate hypoperfusion at a low DBP. The management of BP might, therefore, require modification of targets according to the revascularization strategy to improve outcomes.
先前接受过血运重建的高血压合并冠心病患者的最佳血压（BP）以预防主要不良结局（死亡、心肌梗死和卒中）尚不清楚，但可能受到血运重建类型的影响。我们分析了国际维拉帕米 SR-trandolapril 研究（INTERNATIONAL VErapamil SR-Trandolapril STudy）的数据，该研究聚焦于 6166 例先前接受过血运重建的患者的 BP 与结局之间的关系，同时以 16410 例未接受血运重建的患者作为参考组。先前的血运重建策略包括冠状动脉旁路移植术（CABG，45.2%）、经皮冠状动脉介入治疗（PCI，42.1%）或两者兼有（CABG+PCI，12.8%）。同时接受 CABG+PCI 和单纯 CABG 的患者不良结局风险更高（校正后的危险比分别为 1.27%和 1.20%，95%置信区间分别为 1.06 至 1.53 和 1.07 至 1.35）。仅接受 PCI 的患者风险相似（校正后的危险比为 1.04，95%置信区间为 0.92 至 1.19）。对于每种血运重建策略，校正后的危险比与治疗中的 BP 之间的关系呈 J 形，在 PCI 和舒张压（DBP）中更为明显，但对于单纯 CABG 和 DBP 除外，它们之间的关系呈线性且为正。总之，与先前仅接受 PCI 的患者相比，先前接受过 CABG 治疗或同时接受过 CABG 和 PCI 治疗的冠心病患者发生主要不良结局的频率更高。这可能反映了更严重的血管疾病。对于每种策略，与收缩压的关系呈 J 形。对于仅接受过 CABG 的患者，与 DBP 之间的线性关系提示更完全的血运重建可能会减轻低 DBP 时的灌注不足。因此，BP 的管理可能需要根据血运重建策略修改目标，以改善结局。
