Bert Andersson1, Lilin She2, Ru-San Tan3, Panniyammakal Jeemon4, Krzysztof Mokrzycki5, Matthias Siepe6, Alexander Romanov7, Liliana E Favaloro8, Ljubomir T Djokovic9, P Krishnam Raju10, Piotr Betlejewski11, Normand Racine12, Adam Ostrzycki13, Weerachai Nawarawong14, Siuli Das15, Jean L Rouleau12, George Sopko16, Kerry L Lee2,17, Eric J Velazquez2,18, Julio A Panza19. 1. Department of Cardiology, Blå Stråket 3, Sahlgrenska University Hospital, Gothenburg, Sweden. 2. Duke Clinical Research Institute, 2400 Pratt Street Durham, NC, USA. 3. National Heart Centre, 5 Hospital Drive, Singapore. 4. Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695011, India, and Centre for Chronic Disease Control, New Delhi, India. 5. Department of Cardiac Surgery, SPSK-2, Pomeranian Medical University, Powstanców Wielkopolskich 72, Szczecin, Poland. 6. Klinik für Herz- und Gefässchirurgie, Universitäts Herzzentrum Freiburg Bad Krozingen, Südring 15, Bad Krozingen, Germany. 7. Arrhythmia Department and Electrophysiology Laboratory, State Research Institute of Circulation Pathology, Rechkunovskaya 15, Novosibirsk, Russia. 8. Hospital Universitario Fundación Favaloro, Av. Belgrano 1782 (C1093AAS), Ciudad Autónoma de Buenos Aires, Argentina. 9. Dedinje Cardiovascular Institute, Heroja Milana Tepica br. 1, Belgrade, Serbia. 10. Care Hospitals, Care op center, Road Number 10, Zahara Nagar, Banjara Hills, Hyderabad, Telangana, India. 11. Klinika Kardiochirurgii, Instytut Kardiologii, Wilenska 44, Gdansk, Poland. 12. Université de Montréal, Montréal Heart Institute, 5000 Belanger est, Montreal, Québec, Canada. 13. National Institute of Cardiology, Alpejska 42, Warsaw, Poland. 14. Department of Surgery, Chiang Mai University, Su Thep, Mueang Chiang Mai District, Chiang Mai, Thailand. 15. Centre for Chronic Disease Conrol, C1/52 2nd Floor, Safdarjung Development Area, New Delhi, India. 16. National Heart, Lung, and Blood Institute, National Institutes of Health, 6701 Rockledge Dr, Bethesda, MD, USA. 17. Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA. 18. Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA. 19. Cardiology, Westchester Medical Center and WMC Health Network, New York Medical College, 100 Woods Road, Macy Pavilion, Room 100 Valhalla, NY, USA.
Abstract
Aims: Hypertension (HTN) is a well-known contributor to cardiovascular disease, including heart failure (HF) and coronary artery disease, and is the leading risk factor for premature death world-wide. A J- or U-shaped relationship has been suggested between blood pressure (BP) and clinical outcomes in different studies. However, there is little information about the significance of BP on the outcomes of patients with coronary artery disease and left ventricular dysfunction. This study aimed to determine the relationship between BP and mortality outcomes in patients with ischaemic cardiomyopathy. Methods and results: The influence of BP during a median follow-up of 9.8 years was studied in a total of 1212 patients with ejection fraction ≤35% and coronary disease amenable to coronary artery bypass grafting (CABG) who were randomized toCABG or medical therapy alone (MED) in the STICH (Surgical Treatment for Ischaemic Heart Failure) trial. Landmark analyses were performed starting at 1, 2, 3, 4, and 5 years after randomization, in which previous systolic BP values were averaged and related to subsequent mortality through the end of follow-up with a median of 9.8 years. Neither a previous history of HTN nor baseline BP had any significant influence on long-term mortality outcomes, nor did they have a significant interaction with MED or CABG treatment. The landmark analyses showed a progressive U-shaped relationship that became strongest at 5 years (χ2 and P-values: 7.08, P = 0.069; 8.72, P = 0.033; 9.86; P = 0.020; 8.31, P = 0.040; 14.52, P = 0.002; at 1, 2, 3, 4, and 5-year landmark analyses, respectively). The relationship between diastolic BP (DBP) and outcomes was similar. The most favourable outcomes were observed in the SBP range 120-130, and DBP 75-85 mmHg, whereas lower and higher BP were associated with worse outcomes. There were no differences in BP-lowering medications between groups. Conclusion: A strong U-shaped relationship between BP and mortality outcomes was evident in ischaemic HF patients. The results imply that the optimal SBP might be in the range 120-130 mmHg after intervention, and possibly be subject to pharmacologic action regarding high BP. Further, low BP was a marker of poor outcomes that might require other interactions and treatment strategies. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.
RCT Entities:
Aims: Hypertension (HTN) is a well-known contributor to cardiovascular disease, including heart failure (HF) and coronary artery disease, and is the leading risk factor for premature death world-wide. A J- or U-shaped relationship has been suggested between blood pressure (BP) and clinical outcomes in different studies. However, there is little information about the significance of BP on the outcomes of patients with coronary artery disease and left ventricular dysfunction. This study aimed to determine the relationship between BP and mortality outcomes in patients with ischaemic cardiomyopathy. Methods and results: The influence of BP during a median follow-up of 9.8 years was studied in a total of 1212 patients with ejection fraction ≤35% and coronary disease amenable to coronary artery bypass grafting (CABG) who were randomized to CABG or medical therapy alone (MED) in the STICH (Surgical Treatment for Ischaemic Heart Failure) trial. Landmark analyses were performed starting at 1, 2, 3, 4, and 5 years after randomization, in which previous systolic BP values were averaged and related to subsequent mortality through the end of follow-up with a median of 9.8 years. Neither a previous history of HTN nor baseline BP had any significant influence on long-term mortality outcomes, nor did they have a significant interaction with MED or CABG treatment. The landmark analyses showed a progressive U-shaped relationship that became strongest at 5 years (χ2 and P-values: 7.08, P = 0.069; 8.72, P = 0.033; 9.86; P = 0.020; 8.31, P = 0.040; 14.52, P = 0.002; at 1, 2, 3, 4, and 5-year landmark analyses, respectively). The relationship between diastolic BP (DBP) and outcomes was similar. The most favourable outcomes were observed in the SBP range 120-130, and DBP 75-85 mmHg, whereas lower and higher BP were associated with worse outcomes. There were no differences in BP-lowering medications between groups. Conclusion: A strong U-shaped relationship between BP and mortality outcomes was evident in ischaemic HFpatients. The results imply that the optimal SBP might be in the range 120-130 mmHg after intervention, and possibly be subject to pharmacologic action regarding high BP. Further, low BP was a marker of poor outcomes that might require other interactions and treatment strategies. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.
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