Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, Tokyo, Japan.
Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, Tokyo, Japan.
Am J Med Sci. 2019 Sep;358(3):219-226. doi: 10.1016/j.amjms.2019.06.007. Epub 2019 Jun 29.
Lowering blood pressure (BP) is important in improving the prognosis of hypertensive patients with coronary artery disease (CAD). Patients suffering CAD with chronic kidney disease (CKD) have poorer prognosis than those without CKD. However, there is limited evidence regarding the benefit of BP-lowering therapy on cardiovascular outcomes in patients with CAD and CKD. In this study, we aimed to evaluate the relation between major adverse cardiac events (MACE) and achieved BP in hypertensive patients with CAD and CKD as a high-risk population.
This study was a post-hoc analysis from the HIJ-CREATE trial, a multicenter, prospective, randomized controlled study comparing the effects of antihypertensive therapy with and without candesartan on MACE in 2049 hypertensive patients with angiographically documented CAD. Of these, 1,002 patients had CKD with a diagnosis of estimated glomerular filtration rate (eGFR) <60 mL/minute/1.73m. The primary endpoint was the time to first MACE. The participants were divided into quartiles based on the mean systolic or diastolic BP during the follow-up period.
Compared between the quartiles, intensive lowering of diastolic BP increased the incidence of MACE in CKD patients; however, intensive lowering of systolic BP did not worsen the incidence of MACE. Therefore, the relationship between achieved diastolic BP and the incidence of MACE showed a "reverse J-shape" curve in the study population.
Intensive lowering of systolic BP in hypertensive patients with CAD and CKD does not correlate with an increased risk of MACE. In contrast, excessive lowering of diastolic BP with antihypertensive treatment results in increased MACE.
降低血压（BP）对于改善患有冠状动脉疾病（CAD）的高血压患者的预后非常重要。患有慢性肾脏病（CKD）的 CAD 患者比没有 CKD 的患者预后更差。然而，关于降压治疗对 CAD 和 CKD 患者心血管结局的益处，证据有限。在这项研究中，我们旨在评估 CAD 和 CKD 高危人群中降压治疗与主要不良心脏事件（MACE）之间的关系。
这是 HIJ-CREATE 试验的事后分析，该试验是一项多中心、前瞻性、随机对照研究，比较了在 2049 例经血管造影证实患有 CAD 的高血压患者中，加用或不加用坎地沙坦的降压治疗对 MACE 的影响。其中，1002 例患者患有 CKD，诊断为肾小球滤过率（eGFR）<60mL/min/1.73m。主要终点是首次 MACE 的时间。根据随访期间的平均收缩压或舒张压，将参与者分为四组。
与四组相比，舒张压的强化降低增加了 CKD 患者 MACE 的发生率；然而，收缩压的强化降低并没有使 MACE 的发生率恶化。因此，研究人群中达到的舒张压与 MACE 发生率之间的关系呈“反向 J 形”曲线。
CAD 和 CKD 高血压患者强化降低收缩压与 MACE 风险增加无关。相反，降压治疗过度降低舒张压会导致 MACE 增加。
