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Goal blood pressure in patients with cardiovascular disease or at high risk

George L Bakris, MD
William B White, MD, FASH, FAHA, FACP
Section Editors
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Norman M Kaplan, MD
Deputy Editor
Gordon M Saperia, MD, FACC


Hypertension is the most prevalent major risk factor for premature cardiovascular disease (CVD), being more common than cigarette smoking, dyslipidemia, and diabetes [1]. (See "Cardiovascular risks of hypertension" and "Overview of the risk equivalents and established risk factors for cardiovascular disease".)

Regarding the relationship between blood pressure (BP) and outcomes in patients with or at risk of CVD:

The risk of the development of a cardiovascular event such as myocardial infarction, stroke, or cardiovascular death is directly related to the level of BP.

The majority of individuals with hypertension have one or more other risk factors [2,3], which augment the cardiovascular risk at any level of blood pressure (figure 1) [4].

The excess risk of a future cardiovascular event attributable to hypertension is greater in individuals with established CVD, diabetes mellitus, or chronic kidney disease compared to those at lower risk.


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Literature review current through: Sep 2016. | This topic last updated: Nov 23, 2015.
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  1. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004; 364:937.
  2. Mancia G, De Backer G, Dominiczak A, et al. 2007 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 2007; 28:1462.
  3. Mancia G, Parati G, Borghi C, et al. Hypertension prevalence, awareness, control and association with metabolic abnormalities in the San Marino population: the SMOOTH study. J Hypertens 2006; 24:837.
  4. Jackson R, Lawes CM, Bennett DA, et al. Treatment with drugs to lower blood pressure and blood cholesterol based on an individual's absolute cardiovascular risk. Lancet 2005; 365:434.
  5. SPRINT Research Group, Wright JT Jr, Williamson JD, et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015; 373:2103.
  6. ACCORD Study Group, Cushman WC, Evans GW, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010; 362:1575.
  7. Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 2000; 342:145.
  8. Dagenais GR, Yusuf S, Bourassa MG, et al. Effects of ramipril on coronary events in high-risk persons: results of the Heart Outcomes Prevention Evaluation Study. Circulation 2001; 104:522.
  9. Bosch J, Yusuf S, Pogue J, et al. Use of ramipril in preventing stroke: double blind randomised trial. BMJ 2002; 324:699.
  10. Sleight P, Yusuf S, Pogue J, et al. Blood-pressure reduction and cardiovascular risk in HOPE study. Lancet 2001; 358:2130.
  11. Svensson P, de Faire U, Sleight P, et al. Comparative effects of ramipril on ambulatory and office blood pressures: a HOPE Substudy. Hypertension 2001; 38:E28.
  12. Fox KM, EURopean trial On reduction of cardiac events with Perindopril in stable coronary Artery disease Investigators. 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.
  13. Daly CA, Fox KM, Remme WJ, et al. The effect of perindopril on cardiovascular morbidity and mortality in patients with diabetes in the EUROPA study: results from the PERSUADE substudy. Eur Heart J 2005; 26:1369.
  14. Brugts JJ, Boersma E, Chonchol M, et al. The cardioprotective effects of the angiotensin-converting enzyme inhibitor perindopril in patients with stable coronary artery disease are not modified by mild to moderate renal insufficiency: insights from the EUROPA trial. J Am Coll Cardiol 2007; 50:2148.
  15. Nissen SE, Tuzcu EM, Libby P, 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.
  16. Braunwald E, Domanski MJ, Fowler SE, et al. Angiotensin-converting-enzyme inhibition in stable coronary artery disease. N Engl J Med 2004; 351:2058.
  17. Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease (TRANSCEND) Investigators, Yusuf S, Teo K, et al. Effects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high-risk patients intolerant to angiotensin-converting enzyme inhibitors: a randomised controlled trial. Lancet 2008; 372:1174.
  18. NAVIGATOR Study Group, McMurray JJ, Holman RR, et al. Effect of valsartan on the incidence of diabetes and cardiovascular events. N Engl J Med 2010; 362:1477.
  19. Poole-Wilson PA, Lubsen J, Kirwan BA, 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.
  20. Baker WL, Coleman CI, Kluger J, et al. Systematic review: comparative effectiveness of angiotensin-converting enzyme inhibitors or angiotensin II-receptor blockers for ischemic heart disease. Ann Intern Med 2009; 151:861.
  21. Thompson AM, Hu T, Eshelbrenner CL, et al. Antihypertensive treatment and secondary prevention of cardiovascular disease events among persons without hypertension: a meta-analysis. JAMA 2011; 305:913.
  22. D'Agostino RB, Belanger AJ, Kannel WB, Cruickshank JM. Relation of low diastolic blood pressure to coronary heart disease death in presence of myocardial infarction: the Framingham Study. BMJ 1991; 303:385.
  23. Messerli FH, Mancia G, Conti CR, et al. Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med 2006; 144:884.
  24. Boutitie F, Gueyffier F, Pocock S, et al. J-shaped relationship between blood pressure and mortality in hypertensive patients: new insights from a meta-analysis of individual-patient data. Ann Intern Med 2002; 136:438.
  25. Staessen J, Bulpitt C, Clement D, et al. Relation between mortality and treated blood pressure in elderly patients with hypertension: report of the European Working Party on High Blood Pressure in the Elderly. BMJ 1989; 298:1552.
  26. Bangalore S, Messerli FH, Wun CC, et al. J-curve revisited: An analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) Trial. Eur Heart J 2010; 31:2897.
  27. Armstrong D, Matangi M, Brouillard D, Myers MG. Automated office blood pressure - being alone and not location is what matters most. Blood Press Monit 2015; 20:204.
  28. Chobanian AV. Time to Reassess Blood-Pressure Goals. N Engl J Med 2015; 373:2093.
  29. Bangalore S, Qin J, Sloan S, et al. What is the optimal blood pressure in patients after acute coronary syndromes?: Relationship of blood pressure and cardiovascular events in the PRavastatin OR atorVastatin Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction (PROVE IT-TIMI) 22 trial. Circulation 2010; 122:2142.
  30. Chrysant SG, Chrysant GS. Effectiveness of lowering blood pressure to prevent stroke versus to prevent coronary events. Am J Cardiol 2010; 106:825.
  31. Mancia G. Effects of intensive blood pressure control in the management of patients with type 2 diabetes mellitus in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Circulation 2010; 122:847.
  32. Sleight P, Redon J, Verdecchia P, et al. Prognostic value of blood pressure in patients with high vascular risk in the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial study. J Hypertens 2009; 27:1360.
  33. Arima H, Chalmers J, Woodward M, et al. Lower target blood pressures are safe and effective for the prevention of recurrent stroke: the PROGRESS trial. J Hypertens 2006; 24:1201.
  34. Rosendorff C, Lackland DT, Allison M, et al. Treatment of Hypertension in Patients With Coronary Artery Disease: A Scientific Statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. J Am Coll Cardiol 2015; 65:1998.
  35. James PA, Oparil S, Carter BL, 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.