Age and blood pressure goal in women with prior coronary events

Abstract

The three more important sequalae of sustained hypertension in the heart, include heart failure (HF), conduction to arrhythmia particularly atrial fibrillation (AF) and coronary artery disease (CAD). In this issue of the journal Sava et al. [1] describe analyzing the data from the INternational VErapamil SR-Trandolapril (INVEST) study [2] the optimal systolic blood pressure (BP) to reduce mortality in women with previous coronary events.

In a very recent review by Mehilli and Presbitero [3] the characteristics of women with CAD and acute coronary syndrome (ACS) are amply described. Women with CAD differ from men by several aspects as the clinical presentation, the accompanying comorbidities and risk factors, as well as, by the delivery of medical care. Moreover, women use to be older and present frequent and pronounced frailty. They present more frequently ACS without obstructive coronary arteries which makes it difficult the diagnosis and treatment of ACS. Importantly, in young women compared to men early death is more frequent in women, as well as, in older women during the first year after an ACS.

The two main Guidelines for the management of arterial hypertension that of European Society of Cardiology (ESC)/European Society of Hypertension (ESH) [4] and that of the American College of Cardiology (ACC)/American Heart Association (AHA) [5] differ in the recommended BP goal for patients with chronic CAD depending on their age. The European Guideline defines the systolic goal BP in patients with CAD as inferior to 130/80 mmHg when the age of the patient is <65 years and between 130 and 139 mmHg whether the age is ≥65 years. The Unite States Guideline defines a goal <130 for every patient with CAD. These goals are the same for men and women albeit these Guidelines contained data from trials enrolling a small number of women that included few patients with CAD [4,5].

The INVEST study [2] included the largest cohort of women with hypertension and chronic CAD. As a consequence, this analysis of Sava et al. [1] is really relevant and has to be applied in daily clinical practice. In synthesis, these authors demonstrate that among women ≥65 years old with arterial hypertension and CAD, in trial systolic BP 130–139 mmHg was associated with lower mortality when compared to values <130 mmHg. Apparently, the recommendation of the European Guideline seems to be more adequate than of the US Guideline for women with both high and low risk accompanying CAD. In patients younger than 65 years both Guidelines recommendation are equal.

In summary, this is an interesting paper that demonstrate the need of a higher consideration of women inclusion in cardiovascular trials.