Böhm Michael, Ferreira João Pedro, Mahfoud Felix, Duarte Kevin, Pitt Bertram, Zannad Faiez, Rossignol Patrick
Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Kardiologie, Angiologie und Internistische Intensivmedizin, Kirrberger Str. 1, 66421 Homburg/Saar, Germany.
Centre d'Investigation Clinique Plurithématique Pierre Drouin-INSERM CHU de Nancy, Nancy, France.
Eur Heart J. 2020 May 1;41(17):1673-1683. doi: 10.1093/eurheartj/ehaa132.
The described association of low diastolic blood pressure (DBP) with increased cardiovascular outcomes could be due to reduced coronary perfusion or is simply due to reverse causation. If DBP is physiologically relevant, coronary reperfusion after myocardial infarction (MI) might influence DBP-risk association.
The relation of achieved DBP with cardiovascular death or cardiovascular hospitalization, cardiovascular death, and all-cause death was explored in 5929 patients after acute myocardial infarction (AMI) with impaired left ventricular function, signs and symptoms of heart failure, or diabetes in the EPHESUS trial according to their reperfusion status. Cox regression models were used to assess the impact of reperfusion status on the association of DBP and systolic blood pressure (SBP) with outcomes in an adjusted fashion. In patients without reperfusion, lower DBP <70 mmHg was associated with increased risk for all-cause death [adjusted hazard ratios (HRs) 1.80, 95% confidence interval (CI) 1.41-2.30; P < 0.001], cardiovascular death (HR 1.70, 95% CI 1.3-3.22; P < 0.001), cardiovascular death or cardiovascular hospitalization (HR 1.54, 95% CI 1.26-1.87; P < 0.001). In patients with reperfusion, the risk increase at low DBP was not observed. At low SBP, risk increased independently of reperfusion. A sensitivity analysis in the subgroup of patients with optimal SBP of 120-130 mmHg showed again risk reduction of reperfusion at low DBP. Adding the treatment allocation to eplerenone or placebo into the models had no effects on the results.
Patients after AMIs with a low DBP had an increased risk, which was sensitive to reperfusion therapy. Low blood pressure after MI identifies in patients with particular higher risk. These data support the hypothesis that low DBP in patients with stenotic coronary lesions is associated with risk, potentially involving coronary perfusion pressure and the recommendations provided by guidelines suggesting lower DBP boundaries for these high-risk patients.
舒张压（DBP）降低与心血管疾病预后增加之间的关联，可能是由于冠状动脉灌注减少，或者仅仅是由于反向因果关系。如果DBP具有生理相关性，那么心肌梗死（MI）后的冠状动脉再灌注可能会影响DBP与风险之间的关联。
在EPHESUS试验中，根据再灌注状态，对5929例急性心肌梗死（AMI）后出现左心室功能受损、心力衰竭体征和症状或糖尿病的患者，探讨达到的DBP与心血管死亡或心血管住院、心血管死亡以及全因死亡之间的关系。采用Cox回归模型，以调整后的方式评估再灌注状态对DBP和收缩压（SBP）与预后关联的影响。在未进行再灌注的患者中，较低的DBP<70 mmHg与全因死亡风险增加相关[调整后的风险比（HRs）为1.80，95%置信区间（CI）为1.41 - 2.30；P < 0.001]，心血管死亡（HR为1.70，95% CI为1.3 - 3.22；P < 0.001），心血管死亡或心血管住院（HR为1.54，95% CI为1.26 - 1.87；P < 0.001）。在进行再灌注的患者中，未观察到低DBP时风险增加。在低SBP时，风险增加与再灌注无关。对SBP为120 - 130 mmHg的最佳SBP患者亚组进行的敏感性分析再次显示，低DBP时再灌注可降低风险。将依普利酮或安慰剂的治疗分配加入模型对结果无影响。
AMI后DBP较低的患者风险增加，这对再灌注治疗敏感。MI后低血压在特定高风险患者中具有识别意义。这些数据支持以下假设，即冠状动脉狭窄病变患者的低DBP与风险相关，可能涉及冠状动脉灌注压，以及指南中为这些高风险患者建议的较低DBP界限。
