December 8, 2009Hypertension126 citations
View Full PaperEffect of Intensive Versus Standard Blood Pressure Lowering on Diastolic Function in Patients With Uncontrolled Hypertension and Diastolic Dysfunction
Structured PICO
Does intensive blood pressure lowering improve diastolic function compared to standard blood pressure lowering in patients with uncontrolled hypertension and diastolic dysfunction?
P
Population
228 patients with uncontrolled hypertension, preserved ejection fraction, and diastolic dysfunction
I
Intervention
Intensive blood pressure lowering strategy (systolic blood pressure target <130 mm Hg) using a combination of valsartan (160 or 320 mg) plus amlodipine (5 or 10 mg), with other antihypertensive medications as needed
C
Comparator
Standard blood pressure lowering strategy (systolic blood pressure target <140 mm Hg) using a combination of valsartan (160 or 320 mg) plus amlodipine (5 or 10 mg), with other antihypertensive medications as needed
O
Outcome
Echocardiographic assessment of diastolic function (myocardial relaxation velocity) at 24 weekssurrogate
Intensive blood pressure lowering to <130 mm Hg did not significantly improve diastolic function compared to standard lowering to <140 mm Hg, although greater systolic blood pressure reduction was associated with better final diastolic relaxation velocities.
Abstract
Diastolic dysfunction may precede development of heart failure in hypertensive patients. We randomized 228 patients with uncontrolled hypertension, preserved ejection fraction, and diastolic dysfunction to 2 targeted treatment strategies: intensive, with a systolic blood pressure target of <130 mm Hg, or standard, with a systolic blood pressure target of <140 mm Hg, using a combination of valsartan, either 160 or 320 mg, plus amlodipine, either 5 or 10 mg, with other antihypertensive medications as needed. Echocardiographic assessment of diastolic function was performed at baseline and after 24 weeks in a prospective, open-label, blinded end point design. Blood pressure was reduced significantly in both groups, from 161.2+/-13.9/90.1+/-12.0 to 130.8+/-12.3/74.9+/-9.1 mm Hg (P<0.0001) in the intensive arm and from 162.1+/-13.2/93.7+/-12.2 to 137.0+/-12.9/79.6+/-11.0 mm Hg (P<0.0001) in the standard arm (P<0.003 for between-group comparisons). Myocardial relaxation velocity improved from 7.6+/-1.1 to 9.2+/-1.7 cm/s (Delta 1.54+/-1.4 cm/s; P<0.0001) in the intensive arm and from 7.5+/-1.3 to 9.0+/-1.9 cm/s (Delta 1.48+/-1.6 cm/s; P<0.0001) in the standard arm, with no difference between the 2 strategies in the achieved improvement (P=0.58). The degree of improvement in annular relaxation velocity was associated with the extent of systolic blood pressure reduction, and patients with the lowest achieved systolic blood pressure had the highest final diastolic relaxation velocities.