The American Heart Association (AHA), the American College of Cardiology (ACC), and the American Society of Hypertension (ASH) recently issued new recommendations for treating hypertension in patients who have been diagnosed with coronary heart disease, stroke, or other forms of heart disease. The 3 medical organizations jointly issued a statement published in the AHA’s journal Hypertension in which they addressed treatment goals for patients with high blood pressure who also have vascular diseases (Table).

Coronary Artery Disease
Coronary artery disease (CAD) develops when the coronary arteries become damaged or diseased. Coronary arteries are the major blood vessels that supply the heart with blood, oxygen, and nutrients. When plaques (cholesterolcontaining deposits) build up, they narrow the coronary arteries, decreasing blood flow to the heart. Eventually, the decreased blood flow may cause chest pain (angina), shortness of breath, and a heart attack (if blockage is complete).

Measuring Blood Pressure
Blood pressure is recorded as 2 numbers: systolic and diastolic. These numbers measure the amount of force pushing against arterial walls when the heart is contracting and when the heart is at rest. The systolic measurement is the top number and the higher of the 2 numbers; it measures the pressure in the arteries when the heart muscle contracts. The diastolic measurement is the bottom number and the lower of the 2 numbers; it measures the pressure in the arteries when the heart muscle is resting between beats and refilling with blood.

More attention is usually given to systolic blood pressure, rather than diastolic blood pressure, as a major risk factor for cardiovascular disease in people older than 50 years. As we age, systolic blood pressure tends to rise due to increasing stiffness of large arteries, plaque buildup, and increased incidence of cardiac and vascular disease. than diastolic blood pressure, as a major risk factor for cardiovascular disease in people older than 50 years. As we age, systolic blood pressure tends to rise due to increasing stiffness of large arteries, plaque buildup, and increased incidence of cardiac and vascular disease.

Management of Hypertension with CAD
Management of hypertension in patients with chronic CAD focuses on the prevention of death, heart attack, and stroke; the reduction of myocardial ischemia (reduced blood flow to the heart); and the improvement of symptoms. This is accomplished with lifestyle modifications and medication therapy.

Blood Pressure Targets in Patients with CAD
The AHA/ACC/ASH guidelines emphasize that although a target of less than 140/90 mm Hg is reasonable to avoid heart attacks and strokes, a lower target of less than 130/80 mm Hg may be appropriate in some individuals with heart disease who have already experienced a stroke, heart attack, or mini-stroke (also called a transient ischemic attack) or who have other cardiovascular conditions, such as a narrowing of leg arteries or abdominal aortic aneurysm. In patients with coronary artery blockages, the guidelines recommend that blood pressure should be lowered slowly and that in patients older than 60 years, diastolic blood pressure less than 60 mm Hg is not recommended because it raises the potential for cardiovascular risk.

The guidelines issued by the 3 medical organizations offer specific, evidence-based recommendations to help clinicians select anti-hypertensive medications for use in patients with various types of heart disease. Several drugs are available for the treatment of hypertension, although a beta-blocker is likely suitable for most patients with CAD, by itself or in combination with other classes of drugs. In addition to their effect on blood pressure, beta-blockers relieve stress on the heart by slowing the heart rate and reducing the force with which the heart muscle contracts, both of which reduce the heart’s consumption of oxygen. They also increase blood flow to the heart by prolonging the time between contractions, which is when blood flows into the heart muscle.

Although medications are a mainstay of treatment, the new guidelines also recognize the importance of lifestyle modifications such as smoking cessation, weight loss, reduced sodium intake, exercise, healthy diet, and moderation of alcohol consumption in those who drink.


Beth is a clinical pharmacist and medical editor residing in Northern California.