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Effects of lowering diastolic blood pressure to <80 mmHg on cardiovascular mortality and events in patients with coronary artery disease: a systematic review and meta-analysis


The target of diastolic blood pressure (DBP) remains controversial in patients with coronary artery disease (CAD). We systematically searched PubMed/Medline and the Cochrane Central database for randomized controlled trials (RCTs) assessing the efficacy and safety of reducing DBP in CAD patients from January 1965 to July 2017. Seven placebo-controlled RCTs enrolling 34,814 CAD patients who achieved DBP <80 mmHg were included in the drug-intervention group. The average achieved blood pressures (BPs) were 126.3/75.1 and 131.5/77.8 mmHg in the drug-intervention and placebo-control groups, respectively. Drug intervention was associated with an 11% reduction in coronary revascularization and a 31% reduction in heart failure. In the drug-intervention group, all-cause death, myocardial infarction, angina pectoris, and stroke were reduced with marginal significance, whereas hypotension was increased by 123%. A meta-analysis of four RCTs, in which the achieved DBP was <75 mmHg, showed that the drug intervention was associated with a 22% reduction in heart failure. These results suggest that reducing DBP to 80 mmHg or less would significantly reduce coronary revascularization and heart failure but at the expense of causing hypotension in CAD patients. Further trials are warranted to prove this issue.

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  1. Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903–13.

    Article  Google Scholar 

  2. Wakugami K, Iseki K, Kimura Y, Okumura K, Ikemiya Y, Muratani H, et al. Relationship between serum cholesterol and the risk of acute myocardial infarction in a screened cohort in Okinawa, Japan. Jpn Circ J. 1998;62:7–14.

    Article  CAS  Google Scholar 

  3. Turnbull F. Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials. Lancet. 2003;362:1527–35.

    Article  CAS  Google Scholar 

  4. Shimamoto K, Ando K, Fujita T, Hasebe N, Higaki J, Horiuchi M, Japanese Society of Hypertension Committee for Guidelines for the Management of Hypertension. et al. The Japanese Society of Hypertension Guidelines for the management of hypertension (JSH 2014). Hypertens Res. 2014;37:253–390.

    Article  Google Scholar 

  5. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507–20.

    Article  CAS  Google Scholar 

  6. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013;34:2159–219.

    Article  Google Scholar 

  7. Kang YY, Wang JG. The J-curve phenomenon in hypertension. Pulse (Basel). 2016;4:49–60.

    Article  Google Scholar 

  8. Tanna MS, Bangalore S. Antihypertensive therapy and the J-curve: fact or fiction? Curr Hypertens Rep. 2015;17:6.

    Article  Google Scholar 

  9. Vidal-Petiot E, Ford I, Greenlaw N, Ferrari R, Fox KM, Tardif JC, CLARIFY Investigators. et al. Cardiovascular event rates and mortality according to achieved systolic and diastolic blood pressure in patients with stable coronary artery disease: an international cohort study. Lancet. 2016;388:2142–52.

    Article  Google Scholar 

  10. Khan NA, Rabkin SW, Zhao Y, McAlister FA, Park JE, Guan M, et al. Effect of lowering diastolic pressure in patients with and without cardiovascular disease: analysis of the SPRINT (Systolic Blood Pressure Intervention Trial). Hypertension. 2018;71:840–7.

    Article  CAS  Google Scholar 

  11. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:1269–324.

    Article  CAS  Google Scholar 

  12. SPRINT Research Group, Wright JT Jr., Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103–16.

    Article  Google Scholar 

  13. Bangalore S, Kumar S, Volodarskiy A, Messerli FH. Blood pressure targets in patients with coronary artery disease: observations from traditional and Bayesian random effects meta-analysis of randomised trials. Heart. 2013;99:601–13.

    Article  Google Scholar 

  14. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.

    Article  Google Scholar 

  15. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–60.

    Article  Google Scholar 

  16. Poole-Wilson PA, Lubsen J, Kirwan BA, van Dalen FJ, Wagener G, Danchin N, Coronary disease Trial Investigating Outcome with Nifedipine gastrointestinal therapeutic system investigators. et al. Effect of long-acting nifedipine on mortality and cardiovascular morbidity in patients with stable angina requiring treatment (ACTION trial): randomised controlled trial. Lancet. 2004;364:849–57.

    Article  CAS  Google Scholar 

  17. Nissen SE, Tuzcu EM, Libby P, Thompson PD, Ghali M, Garza D, CAMELOT Investigators. et al. Effect of antihypertensive agents on cardiovascular events in patients with coronary disease and normal blood pressure: the CAMELOT study: a randomized controlled trial. JAMA. 2004;292:2217–25.

    Article  CAS  Google Scholar 

  18. Fox KM. Efficacy of perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet. 2003;362:782–8.

    Article  CAS  Google Scholar 

  19. Rouleau JL, Warnica WJ, Baillot R, Block PJ, Chocron S, Johnstone D, IMAGINE (Ischemia Management with Accupril post-bypass Graft via Inhibition of the coNverting Enzyme) Investigators. et al. Effects of angiotensin-converting enzyme inhibition in low-risk patients early after coronary artery bypass surgery. Circulation. 2008;117:24–31.

    Article  CAS  Google Scholar 

  20. MacMahon S, Sharpe N, Gamble G, Clague A, Mhurchu CN, Clark T, et al. Randomized, placebo-controlled trial of the angiotensin-converting enzyme inhibitor, ramipril, in patients with coronary or other occlusive arterial disease. PART-2 Collaborative Research Group. Prevention of Atherosclerosis with Ramipril. J Am Coll Cardiol. 2000;36:438–43.

    Article  CAS  Google Scholar 

  21. Braunwald E, Domanski MJ, Fowler SE, Geller NL, Gersh BJ, Hsia J, PEACE Trial Investigators. et al. Angiotensin-converting-enzyme inhibition in stable coronary artery disease. N Engl J Med. 2004;351:2058–68.

    Article  CAS  Google Scholar 

  22. Pitt B, Byington RP, Furberg CD, Hunninghake DB, Mancini GB, Miller ME, et al. Effect of amlodipine on the progression of atherosclerosis and the occurrence of clinical events. PREVENT Investigators. Circulation. 2000;102:1503–10.

    Article  CAS  Google Scholar 

  23. Rouleau JR, Simard D, Blouin A, Kingma JG Jr. Angiotensin inhibition and coronary autoregulation in a canine model of LV hypertrophy. Basic Res Cardiol. 2002;97:384–91.

    Article  CAS  Google Scholar 

  24. Messerli FH, Mancia G, Conti CR, Hewkin AC, Kupfer S, Champion A, et al. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med. 2006;144:884–93.

    Article  Google Scholar 

  25. Denardo SJ, Gong Y, Nichols WW, Hewkin AC, Kupfer S, Champion A, et al. Blood pressure and outcomes in very old hypertensive coronary artery disease patients: an INVEST substudy. Am J Med. 2010;123:719–26.

    Article  Google Scholar 

  26. Kai H, Ueno T, Kimura T, Adachi H, Furukawa Y, Kita T, Imaizumi T, CREDO-Kyoto Investigators. Low DBP may not be an independent risk for cardiovascular death in revascularized coronary artery disease patients. J Hypertens. 2011;29:1889–96.

    Article  CAS  Google Scholar 

  27. Kai H, Kimura T, Fukuda K, Fukumoto Y, Kakuma T, Furukawa Y. Impact of low diastolic blood pressure on risk of cardiovascular death in elderly patients with coronary artery disease after revascularization–The CREDO-Kyoto Registry Cohort-1. Circ J. 2016;80:1232–41.

    Article  CAS  Google Scholar 

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Correspondence to Ryuji Okamoto.

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Conflict of interest

The Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, received research grants from Bristol-Myers Squibb, MSD K.K., Pfizer Japan Inc., Takeda Pharmaceutical Co., Ltd., Astellas Pharma Inc., Daiichi Sankyo Pharmaceutical Co., Ltd., Genzyme Japan, Shionogi & Co., Ltd., Sumitomo Dainippon Pharma Co., Ltd., Mitsubishi Tanabe Corporation, Otsuka Pharmaceutical Co., Ltd., Bayer Yakuhin, Ltd., AstraZeneca K.K., and Boehringer Ingelheim Co., Ltd. Rei Shibata received honoraria from Medtoronic, Boehringer Ingelheim, Eli Lilly and Mitsubishi Tanabe Pharma. Toshio Ohtsubo received lecture fees from Sanwa Kagaku Kenkyusho Co., Ltd. Hisashi Kai received lecture fees from Daiichi Sankyo Co Pharmaceutical Co., Ltd., Mitsubishi Tanabe Corporation, Shionogi & Co., Ltd., Sumitomo Dainippon Pharma Co., Ltd., and Takeda Pharmaceutical Co., Ltd. Masaaki Ito received lecture fees from Daiichi Sankyo Co Pharmaceutical Co., Ltd., Mitsubishi Tanabe Corporation, Bayer Yakuhin, Ltd. and Takeda Pharmaceutical Co., Ltd.

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Okamoto, R., Kumagai, E., Kai, H. et al. Effects of lowering diastolic blood pressure to <80 mmHg on cardiovascular mortality and events in patients with coronary artery disease: a systematic review and meta-analysis. Hypertens Res 42, 650–659 (2019).

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  • Coronary artery disease
  • diastolic blood pressure
  • hypertension
  • J curve
  • meta-analysis

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