Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology

Under the heading ‘Hypertension, diabetes, and other disorders’ on page 1358, the guidelines1 lean on the taskforce report on CVD prevention2 suggesting ‘considering a lower threshold for institution of pharmacological therapy for hypertension (130/85) for patients with established coronary heart disease (which would include patients with angina and non-invasive or invasive confirmation of coronary disease)’. Although this statement may be appropriate for the prevention of cardiovascular disease, hypertensive patients with manifest coronary artery disease need a more differentiated approach with regard to target blood pressure. On the basis of our recent findings of a subanalysis of the 22 000 patient INVEST study,3 we would like to caution about too aggressive blood pressure lowering in hypertensive patients with coronary artery disease. This holds particularly true for diastolic pressure and less so for systolic pressure. In our study, the nadir for primary outcome (all-cause death and total MI) was J-shaped, with a nadir at 119/84 mmHg.3 When diastolic pressure dropped below 70 mmHg, the adjusted hazard ratio of primary outcome doubled, and below 60 mmHg, it quadrupled. Since the coronary arteries are perfused during diastole only, it is not surprising that the coronary perfusion becomes hampered when diastolic pressure falls excessively in patients at risk, i.e. those with coronary artery disease. Thus, a cautionary statement, to the effect that low diastolic pressure should be avoided in hypertensive patients with coronary artery disease, would seem appropriate for the otherwise very thorough and comprehensive guidelines.