Impact of resting heart rate on outcomes in hypertensive patients with coronary artery disease: findings from the INternational VErapamil-SR/trandolapril STudy (INVEST)
Key result
Verapamil-SR matches atenolol for major cardiovascular events despite less resting heart rate reduction.
- 95% CI 0.90-1.06
- P=0.62
Why the study?
To evaluate the relationship between resting heart rate and adverse outcomes in CAD patients treated for hypertension with different resting heart rate-lowering strategies.
Does a verapamil-SR-based strategy compared to an atenolol-based strategy reduce adverse outcomes in hypertensive patients with coronary artery disease?
Key Points
- The aim is to establish the link between resting heart rate and adverse outcomes in hypertensive coronary artery disease patients treated with different strategies.
- Assessed time to adverse outcomes (death, non-fatal myocardial infarction, non-fatal stroke) in patients from the INVEST study.
- Compared two treatment strategies: verapamil-SR and atenolol, focusing on their effects on resting heart rate.
- Analyzed baseline and follow-up resting heart rate relationships with adverse outcomes.
- Higher baseline and follow-up resting heart rates were linked to increased risk of adverse outcomes.
- Atenolol reduced resting heart rate more effectively than verapamil-SR, but adverse outcomes were similar between groups (Ve 9.67% vs. At 9.88%).
- For the same resting heart rate, men experienced a higher risk than women.
Study Design
Type
RCT
Multicenter
Yes
Structured PICO
Does a verapamil-SR-based strategy compared to an atenolol-based strategy reduce adverse outcomes in hypertensive patients with coronary artery disease?
P
Population
Hypertensive patients with coronary artery disease (CAD) from the INternational VErapamil-SR/trandolapril STudy (INVEST)
I
Intervention
Verapamil-SR-based strategy
C
Comparator
Atenolol-based strategy
O
Outcome
Composite of death, non-fatal myocardial infarction, or non-fatal strokecomposite
Main Result
Absolute Event Rate: 9.67% vs 9.88%
p-value: p=0.62
In hypertensive patients with coronary artery disease, resting heart rate predicts adverse outcomes, but achieving a lower resting heart rate with an atenolol-based strategy versus a verapamil-SR-based strategy does not further reduce adverse clinical events.
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Now there's an alternative to what's considered the standard of care. The big problem with hypertension is treatment and compliance with treatment. Surveys show that perhaps only 30 percent or less of the patients in the United States who are known to be hypertensive are on treatment and even a smaller percentage are at blood pressure goal for their treatment. It is believed that an important reason for that is the inability to tolerate the treatments. So here we have an alternative treatment strategy that appears to be just as good in terms of preventing adverse outcomes and maybe even better in terms of preventing the emergence of new diabetes cases.”
“The bottom line is it's not as important what you use to treat the high blood pressure as it is to get the blood pressure down.”
Implication
RHR monitoring during therapy may refine risk stratification in hypertensive CAD; extends evidence that on-treatment values outperform baseline for predicting death, MI, or stroke.
Abstract
AIM: To determine the relationship between resting heart rate (RHR) and adverse outcomes in coronary artery disease (CAD) patients treated for hypertension with different RHR-lowering strategies. METHODS AND RESULTS: Time to adverse outcomes (death, non-fatal myocardial infarction, or non-fatal-stroke) and predictive values of baseline and follow-up RHR were assessed in INternational VErapamil-SR/trandolapril STudy (INVEST) patients randomized to either a verapamil-SR (Ve) or atenolol (At)-based strategy. Higher baseline and follow-up RHR were associated with increased adverse outcome risks, with a linear relationship for baseline RHR and J-shaped relationship for follow-up RHR. Although follow-up RHR was independently associated with adverse outcomes, it added less excess risk than baseline conditions such as heart failure and diabetes. The At strategy reduced RHR more than Ve (at 24 months, 69.2 vs. 72.8 beats/min; P < 0.001), yet adverse outcomes were similar [Ve 9.67% (rate 35/1000 patient-years) vs. At 9.88% (rate 36/1000 patient-years, confidence interval 0.90-1.06, P = 0.62)]. For the same RHR, men had a higher risk than women. CONCLUSION: Among CAD patients with hypertension, RHR predicts adverse outcomes, and on-treatment RHR is more predictive than baseline RHR. A Ve strategy is less effective than an At strategy for lowering RHR but has a similar effect on adverse outcomes.
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Cite This Study
Kolloch et al. (2007) conducted an RCT in Hypertension with coronary artery disease. Verapamil-SR-based strategy vs. Atenolol-based strategy was evaluated on Death, non-fatal myocardial infarction, or non-fatal stroke (95% CI 0.90-1.06, p=0.62). A verapamil-SR strategy resulted in similar rates of death, non-fatal MI, or non-fatal stroke compared to an atenolol strategy (9.67% vs 9.88%; P=0.62), despite less resting heart rate reduction.