Hypertension and Coronary Artery Disease:Management Strategies and Guidelines
C.Richard Conti M.D. MACC
GWICC 2004
Beijing PRC
Morbidity and Mortality in Contemporary CAD Patients With Hypertension Treated With Either a Verapamil/Trandolapril or Beta-Blocker/Diuretic Strategy
C.Richard Conti MD, MACC,
Division of Cardiovascular Medicine
University of Florida College of Medicine
Gainesville, Florida
USA
Design
Prospective, randomized, open trial with blinded endpoint evaluation (PROBE) to assess outcomes (death, MI, stroke) in hypertensive CAD patients treated with either a calcium antagonist based (verapamil SR) or noncalcium antagonist based (atenolol) treatment strategy
Hypothesis
Treatment strategies are equivalent (CI 0.83,1.20)
BP Goals
According to JNC VI (< 130/<85 mmHg for pts with diabetes and renal dysfunction, <140/<90 mmHg for all others)
Study Characteristics
Conducted in 862 Sites in 14 Countries
Recruitment from 9/97-12/00; 22,576 patients randomized (ITT)
Follow-up completed end of 2/03
Preliminary results 4/2/03; updated results 9/3/03
INVEST
Time (Months)
Diastolic
Systolic
CAS (n) 11,267
NCAS (n) 11,309
8594 7738 7119 8558 8639 7758 7842 5721 3659
8676 7726 7148 8573 8694 7710 7850 5834 3679
Mean Blood Pressure
p = 0.26
p = 0.41
Change in BP (mmHg)
Systolic
Diastolic
24 Months
Overall BP Control at 24 Months
% Patients
BP Goal
<140/<90 mmHg
--INVEST--
-- ALLHAT --
63
63
71
61
57
54
72
0
10
20
30
40
50
60
70
80
48
45
-- LIFE --
JNC VI
Primary and Secondary Outcomes
Unadjusted Relative Risk with 95% CI
CAS NCAS
n = 8101 n = 8082
Outcome No. (%) No. (%)
New-Onset Diabetes 569 (7.03) 665 (8.23)
Death or
New-Onset Diabetes 1050 (12.97) 1177 (14.57)
Primary Event or
New Onset Diabetes 1185 (14.63) 1313 (16.25)
n= patients without diabetes at baseline
Outcomes in Patients Without Diabetes at Baseline
Unadjusted Relative Risk with 95% CI
Reduced Risk
Increased Risk
Factors Associated With Increased Risk
For The Primary Outcome
Hazard Ratio Estimates From Multivariate Stepwise Model
INVEST
Primary
Results
22,576
Patients
Initiating treatment in hypertensive CAD patients with either a nondihydropyridine CA (verapamil SR)- or a beta-blocker (atenolol)–based BP treatment strategy results in equivalent clinical outcomes and very similar blood pressure control
Either strategy requires multiple drugs (trandolapril and/or HCTZ) in most patients to achieve BP goals
Prevention of death and diabetes by the CA strategy requires confirmation and could have important public health implications
Summary and Conclusions
Initiating treatment in hypertensive CAD patients with either a nondihydropyridine CA (verapamil SR)- or a beta-blocker (atenolol)–based BP treatment strategy results in equivalent clinical outcomes and very similar blood pressure control
Either strategy requires multiple drugs (trandolapril and/or HCTZ) in most patients to achieve BP goals
Prevention of death and diabetes by the CA strategy requires confirmation and could have important public health implications
Summary and Conclusions
JNC VIl - CV Risk Factors
MAJOR
Metabolic Syndrome
HBP, Obesity
Cigarette Smoking
Physical Inactivity
Dyslipidemia
Diabetes Mellitus
Microalbuminuria
Men>55y,Women>65
FH of Premature CV disease, men < 55y,Women < 65
TOD / CCD
LVH, Angina, Prior MI, Prior Revasc, HF
Stroke or TIA
Chronic Kidney Dis
Peripheral Artery Disease
Retinopathy
TOD=target organ damage
CCD=clinical CV disease
JNC Vll
JNC Vll