J-curve revisited: An analysis of blood pressure and cardiovascular events in the Treating to New Targets (TNT) Trial. Hemodynamic Responses to Resistance Exercise in Patients with Coronary Artery Disease. Physical ischaemia induced by isometric exercise facilitated collateral development in the remote ischaemic myocardium of humans. Pulse pressure and risk of cardiovascular outcomes in patients with hypertension and coronary artery disease: an INternational VErapamil SR-trandolapril STudy (INVEST) analysis. Tracking Restoration of Park and Urban Street Settings in Coronary Artery Disease Patients Dogma Disputed: Can Aggressively Lowering Blood Pressure in Hypertensive Patients with Coronary Artery Disease Be Dangerous? Disorders of orthostatic blood pressure response are associated with cardiovascular disease and target organ damage in hypertensive patients. Blood Pressure and Cardiovascular Disease Risk in the Veterans Affairs Diabetes Trial Blood pressure and isolated systolic hypertension and the risk of coronary heart disease and mortality in elderly men (the Zutphen Elderly Study) Blood pressure, stroke, and coronary heart disease: Part 1, prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias A calcium antagonist vs a non-calcium antagonist hypertension treatment strategy for patients with coronary artery disease. The International Verapamil-Trandolapril Study (INVEST): a randomized controlled trial. Blood pressure and outcomes in very old hypertensive coronary artery disease patients: an INVEST substudy. Combination of amlodipine and enalapril in hypertensive patients with coronary disease. Systolic and Diastolic Blood Pressure, Pulse Pressure, and Mean Arterial Pressure as Predictors of Cardiovascular Disease Risk in Men Efficacy and safety of acupuncture for hypertension: An overview of systematic reviews. Plasma levels of estradiol, testosterone, and DHEAS do not predict risk of coronary artery disease in men. Cumulative Blood Pressure in Early Adulthood and Cardiac Dysfunction in Middle Age: The CARDIA Study. Effects of egg ingestion on endothelial function in adults with coronary artery disease: a randomized, controlled, crossover trial. Impact of visit-to-visit variability and systolic blood pressure control on subsequent outcomes in hypertensive patients with coronary artery disease (from the HIJ-CREATE substudy). Efficacy of various antihypertensive agents as evaluated by indices of vascular stiffness in elderly hypertensive patients. Effect of antihypertensive agents on cardiovascular events in patients with coronary disease and normal blood pressure: the CAMELOT study: a randomized controlled trial. Coronary calcification, coronary disease risk factors, C-reactive protein, and atherosclerotic cardiovascular disease events: the St. Francis Heart Study. Effect of oral administration of testosterone on brachial arterial vasoreactivity in men with coronary artery disease.
AIM In patients with coronary artery disease ( CAD ) , a J-curve relationship has been reported between blood pressure ( BP ) and future cardiovascular events . However , this is controversial . The purpose of the study was to determine the relationship between on-treatment BP and cardiovascular outcomes in patients with CAD . METHODS AND RESULTS We evaluated 10 001 patients with CAD and a low-density lipoprotein ( LDL ) cholesterol level < 130 mg/dL , r and omized to atorvastatin 80 vs. 10 mg , enrolled in the TNT trial . The post-baseline , time-dependent BPs [ systolic blood pressure ( SBP ) and diastolic blood pressure ( DBP ) ] were categorized into 10 mmHg increments . The primary outcome was a composite of death from coronary disease , non-fatal myocardial infa rct ion ( MI ) , resuscitated cardiac arrest , and fatal or non-fatal stroke . Among the 10 001 patients , 982 ( 9.82 % ) experienced a primary outcome at 4.9 years ( median ) of follow-up . The relationship between SBP or DBP and primary outcome followed a J-curve with increased event rates above and below the reference BP range , both unadjusted and adjusted ( for baseline covariates , treatment effect , and LDL levels ) . A time-dependent , non-linear , multivariate Cox proportional hazard model identified a nadir of 146.3/81.4 mmHg where the event rate was lowest . A similar non-linear relationship with a higher risk of events at lower pressures was found for most of the secondary outcomes of all-cause mortality , cardiovascular mortality , non-fatal MI , or angina . However , for the outcome of stroke , lower was better for SBP . CONCLUSION In patients with CAD , a low BP ( < 110 - 120/<60 - 70 mmHg ) portends an increased risk of future cardiovascular events ( except stroke ) PURPOSE Investigate hemodynamic responses of resistance exercise ( RE ) with moderate load ( i.e. , international guidelines for RE of patients ) versus RE with high load in patients with coronary artery disease ( CAD ) . METHODS Medically stable male ( n = 11 ) and female patients ( n = 4 ) treated with PCI or percutaneous coronary intervention , or coronary artery bypass surgery a minimum of 6 months before this study , performed three sets of 15RM and 4RM RE in a r and omized order on separate days . Beat-to-beat systolic ( SBP ) , diastolic ( DBP ) blood pressure , heart rate ( HR ) , stroke volume ( SV ) , cardiac output ( CO ) , and systemic vascular resistance ( SVR ) were monitored at preexercise , and continuously during RE . RESULTS Compared with preexercise , SBP and DBP ( mean of three sets ) increased by 12 % to 13 % ( both ; P < 0.001 ) and 35 % to 40 % after 15RM RE ( both ; P < 0.001 ) . 15RM SBP and DBP were higher than 4RM SBP and DBP ( both ; P < 0.001 ) . The SBP of the fourth repetition of 15 RM RE was similar to the SBP of the fourth repetition of 4RM RE . Compared with preexercise , SV increased moderately after 4RM and 15 RM RE , respectively ( both , P < 0.001 ) . HR increased more after 15RM compared with 4RM RE ( P < 0.05 ) ; thus , higher CO after 15RM ( compared with 4RM RE ; P < 0.05 ) was mainly caused by higher HR . SVR decreased by 15 % ( P < 0.001 ) and 50 % ( P < 0.01 ) after 4RM and 15RM RE . CONCLUSIONS SBP and DBP increased significantly more during moderate load RE ; thus , the magnitude of the external load is not the prime determinant of the pressure response during RE . If management of blood pressure is of concern , high load/low rep RE is preferable to medium load/high rep RE The aim of the present study was to investigate the effects of isometric-h and grip-induced PIT ( physical ischaemia training ) on remote coronary recruitment and growth . A total of 74 CAD ( coronary artery disease ) patients were r and omly assigned to either the IHG ( isometric h and grip group ) or NEG ( non-exercise group ) . Patients in the IHG performed isometric h and grip exercises during 1 min of coronary balloon occlusion , whereas patients in the NEG remained sedentary . CFI ( collateral flow index ) , HR ( heart rate ) , SBP ( systolic blood pressure ) and DBP ( diastolic blood pressure ) were evaluated before and at the end of occlusion . In a second study , 21 CAD patients were r and omly divided into the IHT ( isometric h and grip training ) group or the NTG ( non-training group ) . Patients in the IHT group performed 3 months of IHT , whereas patients in the control group remained sedentary . SPECT ( single-photon emission computed tomography ) was used to evaluate myocardial perfusion , and VEGF ( vascular endothelial growth factor ) levels were determined using ELISA . In the IHG , CFI was significantly higher than in the control group ( P<0.01 ) . HR , SBP and DBP in the IHG were significantly higher than in the NEG ( P<0.01 ) at the end of occlusion . In the second study , myocardial perfusion ( P<0.05 ) and left ventricular ejection fraction ( P<0.01 ) were significantly improved in the IHT group . VEGF levels in the IHT group were significantly increased ( P<0.01 ) . Levels of VEGF were negatively correlated with the summed rest score of SPECT ( r=-0.60 , P<0.01 ) . In conclusion , isometric h and grip exercise-induced PIT may promote remote collateral recruitment and growth in CAD patients AIM The purpose of this study was to assess the relationship between  pulse pressure  ( PP ) and cardiovascular outcomes in a large , elderly , coronary artery disease ( CAD ) population with hypertension , and compare the predictive power of PP with other blood pressure measures . METHODS AND RESULTS In INternational VErapamil-tr and olapril STudy , 22,576 CAD patients with hypertension ( mean age 66 years ) were r and omized to verapamil-SR or atenolol-based strategies and followed for 2.7 years ( mean ) . Primary outcome ( PO ) was time to first occurrence of death ( all-cause ) , non-fatal myocardial infa rct ion ( MI ) , or non-fatal stroke . Mean follow-up PP was summarized by 5 mmHg subgroups for association with incidence of PO . Stepwise Cox proportional hazards models were used to estimate adjusted relative hazard ratios ( HR ) for the risk of PO with follow-up PP as a continuous variable , with linear and quadratic terms . Similar models were constructed for follow-up systolic blood pressure ( SBP ) , diastolic blood pressure ( DBP ) , and mean arterial pressures ( MAP ) . A -2 log-likelihood statistic was used to assess the predictive power of PP compared with SBP , DBP , and MAP . For follow-up PP , the incidence and adjusted HR for the PO formed a J- or U-shaped curve . After adjusting for baseline covariates , both linear and quadratic terms for PP were significant ( P < 0.0001 for both ) , with a nadir of 54 mmHg ( bootstrapping 95 % CI 42 - 60 mmHg ) . Similar quadratic relationships were found between PP and all-cause mortality or MI ; the relationship between PP and stroke was linear . Pulse pressure was a predictor of PO even after including SBP ( P = 0.007 linear term ) or DBP ( P < 0.0001 for both linear and quadratic terms ) or MAP ( P < 0.01 for both liner and quadratic terms ) in the model . Using -2 log-likelihood differences , SBP ( -2 log-likelihood difference 77.1 vs. 7.3 for PP ) , DBP ( -2 log-likelihood difference 138.5 vs. 44.6 for PP ) , and MAP ( -2 log-likelihood difference 125.0 vs. 13.4 for PP ) were stronger predictors of PO than PP . CONCLUSION In CAD patients with hypertension , PP ( on anti-hypertensive treatment ) is a weaker predictor of cardiovascular outcomes than SBP , DBP , or MAP The physiological effects of natural and urban environments on the cardiovascular system of coronary artery disease ( CAD ) patients are not fully understood . This controlled field study examines the effects of restorative walking in a park vs. in an urban street environment on CAD patients ’ stress parameters and cardiac function . Methods : Twenty stable CAD patients were r and omly allocated to 7 days controlled walking in a city park or in an urban street environment group . The relationship between different environmental exposures and health effects was analyzed using Wilcoxon signed-rank test and exact Mann-Whitney U test . Results : The mean reduction in cortisol levels and negative effects after the walk on the first day was greater in the city park than in the urban street exposed group , while a reduction in negative effects in the urban group were greater after seven days . The reduction in diastolic blood pressure ( DBP ) in the park group was evident on the seventh day before the walk ( −4 mm Hg , p = 0.031 ) and 60 min after the walk ( −6.00 mm Hg , p = 0.002 ) . The cortisol slope was negatively associated with the DBP changes ( r = −0.514 , p < 0.05 ) . Conclusions : Physical activity in a green environment with noise and air pollution levels lower than in an urban environment has a greater positive effect on CAD patients ’ stress level and hemodynamic parameters . Mitigating green environmental influences may allow urban residents to maintain health and reduce disability Context Experts debate the consequences of excessive lowering of diastolic pressure in patients with hypertension and coronary artery disease . Contribution This report is a secondary analysis of data from a large trial of 2 antihypertensive drug regimens in patients with known coronary artery disease . The authors found a J-shaped relationship between diastolic blood pressure and all-cause death and myocardial infa rct ion , with the increased risk occurring at diastolic blood pressures below 70 to 80 mm Hg , that is , the lower the diastolic pressure , the higher the risk . Caution s The study examined associations between blood pressure and outcomes ; it could not prove that the antihypertensive therapy that lowered diastolic pressure too much caused the adverse outcomes . The Editors For 2 decades , the hypertension literature has been haunted by the phenomenon of a paradoxical increase in morbidity and mortality with an excessive decrease in blood pressure ( J-curve ) . Indeed , several reports have shown that low diastolic pressure is associated with an increased risk for coronary heart disease and related mortality in older adults and in patients taking antihypertensive medications ( 1 - 13 ) . After doing a review and meta- analysis of pertinent studies , Farnett and colleagues ( 14 ) concluded that although there was no consistent J-shaped relationship between stroke and systolic or diastolic pressure , there was a consistent J-shaped relationship for cardiac events and diastolic pressure . These authors stated that this dichotomy in the relationship between diastolic pressure and target organ disease may leave a clinician with the uncomfortable choice of whether to prevent stroke or renal disease at the expense of coronary heart disease . These findings were at variance with the generally accepted dogma formulated by the sixth report of the Joint National Committee on Prevention , Detection , Evaluation , and Treatment of High Blood Pressure ( JNC VI ) ( 15 ) , which stated that the relationship between pressure and risk was strong , continuous , independent , predictive and etiologically significant . Within the past decade , the phenomenon of a J-curve has been studied in several large trials of normotensive and hypertensive patients ( 16 - 30 ) . Not surprisingly , arguments regarding whether a J-curve could be clinical ly significant have become somewhat contentious . That is , some rely on evidence that on-treatment diastolic pressure below 70 mm Hg does not increase risk for cardiovascular disease and thus deny an impairment of vital organ perfusion within the usual values achievable by antihypertensive treatment . Others , however , consider the J-curve a more real possibility , particularly for the heart . In contrast to other organs , the heart is perfused mostly during diastole and thus could be more vulnerable to diastolic pressure reduction . If a J-curve did exist , it should be most evident in patients with limited coronary perfusion , in other words , in those with manifest coronary artery disease ( CAD ) . Optimal blood pressure in patients with hypertension and CAD remains controversial because few r and omized clinical trials have been done in this population ( 31 , 32 ) . The International Verapamil-Tr and olapril Study ( INVEST ) ( 33 ) , a r and omized trial , evaluated more than 22000 patients with CAD and hypertension . This patient profile , together with unprecedented levels of blood pressure control , provided a unique opportunity to critically investigate the hypothesis that the risk for CAD would increase with an excessive decrease in diastolic pressure . Methods Study Design and Intervention The INVEST design , methods , and principal results have been previously published ( 33 ) . The trial used an open design with blinded end point assessment . In brief , clinical ly stable patients with CAD and hypertension were r and omly assigned to a verapamil sustained-releasebased or atenolol-based strategy .  Patients with previous myocardial infa rct ion ( MI ) within 3 months of enrollment or class IV or V congestive heart failure were excluded .  Blood pressure goals were based on JNC VI ( systolic pressure < 140 mm Hg and diastolic pressure < 90 mm Hg or systolic pressure < 130 mm Hg and diastolic pressure < 85 mm Hg in patients with diabetes or renal impairment ) ( 15 ) . The addition of tr and olapril or hydrochlorothiazide was recommended when necessary to achieve blood pressure goals . Tr and olapril was also recommended for patients with heart failure , diabetes , or renal impairment . Documented CAD was defined as any of the following : remote ( 3 months before enrollment ) confirmed MI , coronary angiography showing more than 50 % narrowing of at least 1 major coronary artery , diagnosis of classic angina pectoris , or concordant abnormalities on 2 different signals ( electrocardiography , echocardiography , or radionuclide scans ) from stress test findings concordant for ischemia ( for example , ST-segment depression or perfusion defects on radionuclide scanning or wall-motion abnormalities on echocardiography or radionuclide scanning ) . Patient Monitoring and Follow-up Protocol visits were scheduled every 6 weeks for the first 6 months and then biannually until 2 years after the last patient was enrolled . Patients were assessed for response to treatment , symptoms , treatment adherence , and adverse effects at each visit and at the end of the study as detailed elsewhere ( 33 ) . Patient follow-up was complete when we received a final assessment form through the online data system or a death report . The Internet-based electronic data collection method used in INVEST did not accept the entry until all required fields were complete . Blood pressure  was measured by using a st and ard mercury sphygmomanometer with an appropriately sized cuff applied to the upper nondominant arm at heart level . By auscultation at the brachial artery , systolic pressure was recorded at the first Korotkoff sound and diastolic pressure was recorded at the disappearance of the fifth Korotkoff sound . Blood pressure was measured twice , at least 2 minutes apart , and the measurements were averaged . Study Outcomes The primary outcome was the first occurrence of all-cause death , nonfatal MI , or nonfatal stroke by intention-to-treat analysis . The MI and stroke definitions are detailed elsewhere ( 34 ) . These 3 components individually were the main secondary outcomes . For this analysis , additional outcomes included fatal and nonfatal MI , fatal and nonfatal stroke , and average on-treatment blood pressure before outcome or censoring . Ascertainment and blinded adjudication of outcomes were described previously ( 32 ) . Follow-up data were available for 22008 ( 97.5 % ) patients . Statistical Analysis The main conclusions of INVEST were that the 2 treatment strategies were equivalent with respect to the primary outcome , main secondary outcomes , and on-treatment systolic and diastolic pressures . Thus , data for all enrolled patients were combined and included in these analyses following the intention-to-treat principle . A P value of 0.05 or less was considered statistically significant . Patients without a primary outcome event were censored at their latest follow-up visit . Average follow-up systolic and diastolic pressures were calculated for each patient by using all post-baseline results , up to the date of primary outcome or censoring . The baseline value was substituted for patients with no post-baseline data ( n= 1154 ) . In this exploratory analysis , the proportions of patients were pooled by 10 mm Hg strata of average follow-up systolic pressure , and the distribution of primary outcome event rate was evaluated to determine whether the relationship was linear . A similar presentation was prepared for diastolic pressure . Because the frequency distributions seemed consistent with a quadratic curve , a quadratic Cox proportional hazards model was formed for the time to primary outcome for each blood pressure variable , with factors for blood pressure and blood pressure squared . Similarly , the relationship between each 10 mm Hg stratum of average systolic pressure and diastolic pressure and all-cause death , fatal and nonfatal MI , and fatal and nonfatal stroke was evaluated . For the time to primary outcome , a second model was fitted , adjusting for the following baseline covariates : age ( 10-year increments ) , sex , race and ethnicity ( white , Asian , black , Hispanic , multiracial , or other ) , previous MI , heart failure ( classes I to III ) , body mass index in increments of 5 kg/m2 , U.S. residency , renal impairment , peripheral vascular disease , left ventricular hypertrophy , smoking history , coronary revascularization , dyslipidemia , stroke or transient ischemic attack , angina pectoris , arrhythmia , diabetes , cancer , aspirin use , and average systolic pressure or diastolic pressure and systolic pressure squared or diastolic pressure squared . To identify clinical ly relevant interactions between the J-shaped curve and baseline diastolic pressure , demographic characteristics , and comorbid conditions for the primary outcome , a 2-step procedure was used . First , baseline covariates were tested individually by adding the variable and 2 interaction terms ( variablediastolic pressure and variable[diastolic pressure squared ] ) to the Cox proportional hazards model . Variables included were age older than 70 years , sex , previous MI , heart failure ( classes I to III ) , previous stroke or transient ischemic attack , diabetes , cancer , renal impairment , hypercholesterolemia , peripheral vascular disease , smoking history , U.S. residency , body mass index greater than 29 kg/m2 ( mean baseline body mass index ) , and diastolic pressure greater than 86 mm Hg ( mean baseline diastolic pressure ) . The change in log likelihood was used to assess the significance of simultaneously adding the 2 interaction terms . The second step in identifying clinical ly relevant interactions between the J-shaped curve and baseline covariates was to plot the hazard ratios for the primary outcome versus diastolic pressure in the BACKGROUND The prevalence and clinical significance of orthostatic hypertension  ( OHT ) remain largely undetermined in hypertensive patients . This study investigated the association of OHT and  orthostatic hypotension ( OH )  with cardiovascular disease ( CVD ) and target organ damage ( TOD ) in hypertensive patients . METHODS A cross-sectional study was conducted in 4,711 hypertensives and 826 normotensives , aged 40 - 75 years . OHT was defined as an increase in systolic blood pressure ( SBP ) of > or = 20 mm Hg , and OH was defined as either a reduction in SBP of at least 20 mm Hg or a reduction in diastolic BP ( DBP ) of at least 10 mm Hg during the first 3 min after st and ing . RESULTS Hypertension was only independently associated with a risk of OHT . After controlling for age , sex , and other confounders , OH was associated with peripheral artery disease ( PAD ) ( odds ratio ( OR ) 1.49 , 95 % confidence interval ( CI ) 1.15 - 1.89 , P < 0.01 ) , left ventricular hypertrophy ( LVH ) ( OR 1.48 , 95 % CI 1.12 - 1.93 , P < 0.001 ) , coronary artery disease ( CAD ) ( OR 1.71 , 95 % CI 1.12 - 2.61 , P < 0.01 ) , and stroke ( OR 1.72 , 95 % CI 1.19 - 2.34 , P < 0.01 ) , but OHT was only associated with PAD ( OR 1.36 , 95 % CI 1.05 - 1.81 , P < 0.05 ) and stroke ( OR 1.76 , 95 % CI 1.27 - 2.26 , P < 0.01 ) . The adjusted OR for PAD , predicted by the quintiles of the orthostatic SBP changes , showed a J-shaped relationship in untreated hypertensive patients , as was also the case for LVH in hypertensive women . CONCLUSIONS OH is associated with CV risk ; the associations of OHT with TOD and stroke in hypertensive patients still need to be confirmed in prospect i ve studies OBJECTIVE Blood pressure ranges associated with cardiovascular disease ( CVD ) events in advanced type 2 diabetes are not clear . Our objective was to determine whether baseline and follow-up ( On- Study ) systolic blood pressure ( SBP ) , diastolic blood pressure ( DBP ) , and SBP combined with DBP predict CVD events in the Veterans Affairs Diabetes Trial ( VADT ) . RESEARCH DESIGN AND METHODS Participants in the VADT ( n = 1,791 ) with hypertension received stepped treatment to maintain blood pressure below the target of 130/80 mmHg in st and ard and intensive glycemic treatment groups .  Blood pressure levels of all subjects at baseline and On- Study were analyzed to detect associations with CVD risk . The primary outcome was the time from r and omization to the first occurrence of myocardial infa rct ion , stroke , congestive heart failure , surgery for vascular disease , inoperable coronary disease , amputation for ischemic gangrene , or CVD death . RESULTS Separated SBP ≥140 mmHg had significant risk at baseline ( hazards ratio [ HR ] 1.508 , P < 0.001 ) and On- Study ( HR 1.469 , P = 0.002 ) . DBP < 70 mmHg increased CVD events at baseline ( HR 1.482 , P < 0.001 ) and On- Study ( HR 1.491 , P < 0.001 ) . Combined blood pressure categories indicated high risk for CVD events for SBP ≥140 with DBP < 70 mmHg at baseline ( HR 1.785 , P = 0.03 ) and On- Study ( HR 2.042 , P = 0.003 ) and nearly all SBP with DBP < 70 mmHg . CONCLUSIONS Increased risk of CVD events with SBP ≥140 mmHg emphasizes the urgency for treatment of systolic hypertension . Increased risk with DBP < 70 mmHg , even when combined with SBP in guideline -recommended target ranges , supports a new finding in patients with type 2 diabetes . The results emphasize that DBP < 70 mmHg in these patients was associated with elevated CVD risk and may best be avoided Objective To investigate the associations of diastolic blood pressure ( DBP ) and systolic blood pressure ( SBP ) with the risk of coronary heart disease , sudden cardiac and all-cause death in elderly men . Design A cohort study . Setting The Dutch town of Zutphen . Subjects Eight hundred and eighty-five r and omly selected men , aged 64 - 84 years . Main outcome measures Relative risks adjusted for age , body mass index , total and high-density lipoprotein cholesterol , cigarette smoking , alcohol consumption , use of blood pressure-lowering medications without a specific indication for hypertension , and the physician who measured the blood pressure . Results Neither DBP nor SBP was associated significantly with the incidence of a first coronary heart disease event and no clear associations were observed with mortality from coronary heart disease . However , positive associations with sudden cardiac death were observed . The adjusted relative risk for men with definite isolated systolic hypertension was 9.20 . The risk of dying from coronary heart disease not recorded additionally as sudden death was highest in men at the lower end of the DBP and SBP distributions and in men using antihypertensives . DBP and SBP were positively associated with all-cause mortality when possible comorbidity at the time of the blood pressure measurement was accounted for . Overall , the highest risk for all endpoints was observed in men on antihypertensive medication , who formed a distinct group with a clustering of cardiovascular risk factors . Conclusion Elevated DBP and SBP , and especially isolated systolic hypertension , are important predictors of sudden cardiac death in elderly men . The highest risk of nonsudden coronary heart disease mortality was found at the lower end of the blood pressure distributions and among men on antihypertensive medication The associations of  diastolic blood pressure ( DBP )  with  stroke  and with coronary heart disease ( CHD ) were investigated in nine major prospect i ve observational studies : total 420,000 individuals , 843 strokes , and 4856 CHD events , 6 - 25 ( mean 10 ) years of follow-up . The combined results demonstrate positive , continuous , and apparently independent associations , with no significant heterogeneity of effect among different studies . Within the range of DBP studied ( about 70 - 110 mm Hg ) , there was no evidence of any " threshold " below which lower levels of DBP were not associated with lower risks of stroke and of CHD . Previous analyses have described the uncorrected associations of DBP measured just at " baseline " with subsequent disease rates . But , because of the diluting effects of r and om fluctuations in DBP , these substantially underestimate the true associations of the usual DBP ( ie , an individual 's long-term average DBP ) with disease . After correction for this " regression dilution " bias , prolonged differences in usual DBP of 5 , 7.5 , and 10 mm Hg were respectively associated with at least 34 % , 46 % , and 56 % less stroke and at least 21 % , 29 % , and 37 % less CHD . These associations are about 60 % greater than in previous uncorrected analyses . ( This regression dilution bias is quite general , so analogous corrections to the relations of cholesterol to CHD or of various other risk factors to CHD or to other diseases would likewise increase their estimated strengths . ) The DBP results suggest that for the large majority of individuals , whether conventionally " hypertensive " or " normotensive " , a lower blood pressure should eventually confer a lower risk of vascular disease CONTEXT Despite evidence of efficacy of antihypertensive agents in treating hypertensive patients , safety and efficacy of antihypertensive agents for coronary artery disease ( CAD ) have been discerned only from subgroup analyses in large trials . OBJECTIVE To compare mortality and morbidity outcomes in patients with hypertension and CAD treated with a calcium antagonist strategy ( CAS ) or a non-calcium antagonist strategy ( NCAS ) .  DESIGN , SETTING , AND PARTICIPANTS R and omized , open label , blinded end point study of 22 576 hypertensive CAD patients aged 50 years or older , which was conducted September 1997 to February 2003 at 862 sites in 14 countries . INTERVENTIONS Patients were r and omly assigned to either CAS ( verapamil sustained release ) or NCAS ( atenolol ) . Strategies specified dose and additional drug regimens . Tr and olapril and /or hydrochlorothiazide was administered to achieve blood pressure goals according to guidelines from the sixth report of the Joint National Committee on Prevention , Detection , Evaluation , and Treatment of High Blood Pressure ( JNC VI ) of less than 140 mm Hg ( systolic ) and less than 90 mm Hg ( diastolic ) ; and less than 130 mm Hg ( systolic ) and less than 85 mm Hg ( diastolic ) if diabetes or renal impairment was present . Tr and olapril was also recommended for patients with heart failure , diabetes , or renal impairment . MAIN OUTCOME MEASURES Primary : first occurrence of death ( all cause ) , nonfatal myocardial infa rct ion , or nonfatal stroke ; other : cardiovascular death , angina , adverse experiences , hospitalizations , and blood pressure control at 24 months . RESULTS At 24 months , in the CAS group , 6391 patients ( 81.5 % ) were taking verapamil sustained release ; 4934 ( 62.9 % ) were taking tr and olapril ; and 3430 ( 43.7 % ) were taking hydrochlorothiazide . In the NCAS group , 6083 patients ( 77.5 % ) were taking atenolol ; 4733 ( 60.3 % ) were taking hydrochlorothiazide ; and 4113 ( 52.4 % ) were taking tr and olapril . After a follow-up of 61 835 patient-years ( mean , 2.7 years per patient ) , 2269 patients had a primary outcome event with no statistically significant difference between treatment strategies ( 9.93 % in CAS and 10.17 % in NCAS ; relative risk [ RR ] , 0.98 ; 95 % confidence interval [ CI ] , 0.90 - 1.06 ) . Two-year blood pressure control was similar between groups . The JNC VI blood pressure goals were achieved by 65.0 % ( systolic ) and 88.5 % ( diastolic ) of CAS and 64.0 % ( systolic ) and 88.1 % ( diastolic ) of NCAS patients . A total of 71.7 % of CAS and 70.7 % of NCAS patients achieved a systolic blood pressure of less than 140 mm Hg and diastolic blood pressure of less than 90 mm Hg . CONCLUSION The verapamil-tr and olapril-based strategy was as clinical ly effective as the atenolol-hydrochlorothiazide-based strategy in hypertensive CAD patients BACKGROUND Our underst and ing of the growing population of very old patients ( aged > or=80 years ) with coronary artery disease and hypertension is limited , particularly the relationship between blood pressure and adverse outcomes . METHODS This was a secondary analysis of the INternational VErapamil SR-Tr and olapril STudy ( INVEST ) , which involved 22,576 clinical ly stable hypertensive coronary artery disease patients aged > or=50 years . The patients were grouped by age in 10-year increments ( aged > or=80 , n=2180 ; 70-<80 , n=6126 ; 60-<70 , n=7602 ; < 60 , n=6668 ) . Patients were r and omized to either verapamil SR- or atenolol-based treatment strategies , and primary outcome was first occurrence of all-cause death , nonfatal myocardial infa rct ion , or nonfatal stroke . RESULTS At baseline , increasing age was associated with higher systolic blood pressure , lower diastolic blood pressure , and wider pulse pressure ( P < .001 ) . Treatment decreased systolic , diastolic , and pulse pressure for each age group . However , the very old retained the widest pulse pressure and the highest proportion ( 23.6 % ) with primary outcome . The adjusted hazard ratio for primary outcomes showed a J-shaped relationship among each age group with on-treatment systolic and diastolic pressures . The systolic pressure at the hazard ratio nadir increased with increasing age , highest for the very old ( 140 mm Hg ) . However , diastolic pressure at the hazard ratio nadir was only somewhat lower for the very old ( 70 mm Hg ) . Results were independent of treatment strategy . CONCLUSION Optimal management of hypertension in very old coronary artery disease patients may involve targeting specific systolic and diastolic blood pressures that are higher and somewhat lower , respectively , compared with other age groups BACKGROUND Patients ( pts ) with stable coronary artery disease ( CAD ) can benefit from a decrease in the blood pressure ( BP ) , according to recent studies . OBJECTIVE To evaluate the efficacy and tolerability of the fixed combination : amlodipine + enalapril , when compared to amlodipine in the normalization of the diastolic arterial pressure ( DAP ) ( < 85 mmHg ) , in pts with CAD and systemic arterial hypertension ( SAH ) . METHODS Double-blind and r and omized study , with two groups of pts with DAP > or = 90 and < 110 mmHg and CAD . Patients with left ventricular ejection fraction ( LVEF ) < 40 % , symptoms of heart failure or angina class III and IV , severe diseases and DAP > or = 110 mmHg during the four-week wash-out with atenolol treatment alone , were excluded . After the wash-out , pts were r and omly distributed for the use of the combination ( A ) or amlodipine ( B ) and were followed every four weeks up to 98 days . The initial doses ( in mg ) were , respectively : A- 2.5/10 and B- 2.5 ; the doses were increased when DAP > 85mmHg , at the visits . Statistical analysis was carried out with chi2 , Fischer and analysis of variance , for p < 0.05 . RESULTS Of the 110 selected pts , 72 ( A= 32 , B= 40 ) were r and omized . The decreases in DAP and systolic arterial pressure ( SAP ) were significant ( p < 0.01 ) , but with no difference between the groups in mmHg : SAP , A ( 127.7 + /- 13.4 ) and B ( 125.3 + /- 12.6 ) ( p= 0.45 ) and DAP , A ( 74.5 + /- 6.7 mmHg ) and B ( 75.5 + /- 6.7 mmHg ) ( p= 0.32 ) . Group A presented a lower incidence of lower-limb edema : ( 7.1 % vs 30.6 % , p=0.02 ) on the 98th day of follow-up . CONCLUSION The fixed combination of enalapril and amlodipine , as well as isolated amlodipine , was effective in the normalization of BP in pts with CAD and SAH stages I and II , adding blockage of the renin-angiotensin system We compared systolic blood pressure ( SBP ) , diastolic blood pressure ( DBP ) , pulse pressure ( PP ) , and mean arterial pressure ( MAP ) in predicting the risk of cardiovascular disease ( CVD ) , stratifying results at age 60 years , when DBP decreases while SBP continues to increase . We prospect ively followed 11 150 male physicians with no history of CVD or antihypertensive treatment through the 2-year question naire  ,  after which follow-up began . Reported blood pressure was averaged from both the baseline and 2-year question naires . During a median follow-up of 10.8 years , there were 905 cases of incident CVD . For men aged < 60 years ( n=8743 ) , those in the highest versus lowest quartiles of average SBP ( ≥130 versus < 116 mm Hg ) , DBP ( ≥81 versus < 73 mm Hg ) , and MAP ( ≥97 versus < 88 mm Hg ) had relative risks ( RRs ) of CVD of 2.16 , 2.23 , and 2.52 , respectively . Models with average MAP and PP did not add information compared with models with MAP alone ( P > 0.05 ) . For men aged ≥60 years ( n=2407 ) , those in the highest versus lowest quartiles of average SBP ( ≥135 versus < 120 mm Hg ) , PP ( ≥55 versus < 44 mm Hg ) , and MAP ( ≥99 versus < 91 mm Hg ) had RRs of CVD of 1.69 , 1.83 , and 1.43 , respectively . The addition of other blood pressure measures did not add information compared with average SBP or PP alone ( all P > 0.05 ) . These data suggest that average SBP , DBP , and MAP strongly predict  CVD among younger men , whereas either average SBP or PP predicts CVD among older men . More research should distinguish whether MAP , highly correlated with SBP and DBP , better predicts CVD BACKGROUND AND PURPOSE Acupuncture is widely used in the treatment of hypertension , yet its efficacy and safety for hypertension remain controversial . This overview aim ed to summarize the evidence on acupuncture for hypertension . METHODS Eight data bases were search ed . The Assessment of Multiple Systematic Review s ( AMSTAR ) tool and the Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) approach were performed . RESULTS Fifteen systematic review s ( SRs ) were identified . Method ological quality and quality of evidence were unsatisfactory . Acupuncture combined with Western medicine ( WM ) was superior to WM in systolic blood pressure ( SBP ) and diastolic blood pressure ( DBP ) , efficacy rate , and traditional Chinese medicine ( TCM ) syndrome .  Acupuncture was more effective in treating SBP and DBP than sham acupuncture plus WM . Evidence regarding the benefit of acupuncture alone for SBP and DBP , efficacy rate and TCM syndrome was inconsistent . No serious adverse effects were identified . CONCLUSION High- quality SRs and r and omized controlled trials ( RCTs ) are required Prior studies have reported men with coronary artery disease ( CAD ) to have elevated plasma levels of estrogens and reduced concentrations of dehydroepi and rosterone ( DHEA ) or DHEA-sulfate ( DHEAS ) . We investigated whether gonadal steroids or DHEAS are risk factors for CAD in men , using a prospect i ve design , in a well characterized population studied at regular intervals . We studied 46 men ( Cardiac group ) who developed CAD and 124 men ( Control group ) who remained free of CAD ( mean follow-up , 9.5 years ) . We measured  testosterone ( T ) , estradiol ( E2 ) , and DHEAS  , as well as  plasma binding of T and E2  , in sample s stored before the onset of CAD ( Cardiac group ) or at matched times ( Control group ) . Body mass index , blood pressure , and total serum cholesterol were measured at each visit . Both systolic blood pressure ( SBP ; P less than 0.001 ) and cholesterol ( P less than 0.001 ) were increased in the Cardiac group , but no significant differences were found in total or free T or E2 , the ratio of E2/T , or DHEAS between the two groups . The difference in cholesterol was significant only in men less than or equal to 65 years old ( P less than 0.001 ) , and SBP only in men greater than 65 years old ( P less than 0.005 ) . Cholesterol ( P less than 0.05 ) and E2 ( P less than 0.001 ) appeared to decrease with age in the Cardiac , but not the Control , group . Moreover , total ( P less than 0.01 ) and free E2 ( P less than 0.05 ) were lower only in Cardiac men less than or equal to 55 years old . ( ABSTRACT TRUNCATED AT 250 WORDS BACKGROUND Cumulative blood pressure ( BP ) exposure may adversely influence myocardial function , predisposing individuals to heart failure later in life . OBJECTIVES This study sought to investigate how cumulative exposure to higher BP influences left ventricular ( LV ) function during young to middle adulthood . METHODS The CARDIA ( Coronary Artery Risk Development in Young Adults ) study prospect ively enrolled 5,115 healthy African Americans and whites in 1985 and 1986 ( baseline ) . At the year 25 examination , LV function was measured by 2-dimensional echocardiography ; cardiac deformation was assessed in detail by speckle-tracking echocardiography . We used cumulative exposure of BP through baseline and up to the year 25 examination ( millimeters of mercury × year ) to represent long-term exposure to BP levels . Linear regression and logistic regression were used to quantify the association of BP measured repeatedly through early adulthood ( 18 to 30 years of age ) up to middle age ( 43 to 55 years ) . RESULTS Among 2,479 participants , cumulative BP measures were not related to LV ejection fraction ; however , high cumulative exposure to systolic blood pressure ( SBP ) and diastolic blood pressure ( DBP ) were associated with lower longitudinal strain rate ( both p < 0.001 ) . For diastolic function , higher cumulative exposures to SBP and DBP were associated with low early diastolic longitudinal peak strain rate . Of note , higher DBP ( per SD increment ) had a stronger association with diastolic dysfunction compared with SBP . CONCLUSIONS Higher cumulative exposure to BP over 25 years from young adulthood to middle age is associated with incipient LV systolic and diastolic dysfunction in middle age BACKGROUND Prevailing recommendations call for restricting intake of dietary cholesterol and eggs for those at risk of heart disease , despite accumulating evidence challenging this association . Our prior studies showed no short-term adverse effects of daily egg intake on cardiac risk factors in at-risk adults . OBJECTIVE We conducted this study to determine effects of daily egg consumption in adults with established coronary artery disease ( CAD ) . METHODS R and omized , controlled , single-blind , crossover trial of 32 adults ( mean age , 67 years ; 6 women , 26 men ) with CAD assigned to 1 of 6 possible sequence permutations of 3 different treatments ( breakfast with 2 eggs , breakfast with ½ cup Egg Beaters , ConAgra Foods , St. Louis , MO , or a high-carbohydrate breakfast part of an ad libitum diet ) for 6 weeks , with 4-week washout periods . The primary outcome measure was endothelial function measured as flow-mediated dilatation . RESULTS Compared with the control breakfast ( ie , high-carbohydrate breakfast ) , daily consumption of eggs showed no adverse effects on flow-mediated dilatation ( 7.2 % ± 2.9 % vs 7.5 % ± 2.9 % , P = .33 ) , lipids ( total cholesterol : 158.3 ± 28.6 mg/dL vs 156.2 ± 27.4 mg/dL , P = .49 ) , blood pressure ( systolic blood pressure : 132.8 ± 14.1 mm Hg or vs 135.5 ± 14.9 mm Hg , P = .52 ; diastolic blood pressure : 77.2 ± 6.1 mm Hg vs 76.7 ± 6.9 mm Hg , P = .86 ) , or body weight ( 90.8 ± 17.5 kg vs 91.8 ± 17.1 kg , P = .92 ) . No outcomes differed ( P > .05 ) between eggs and Egg Beaters . CONCLUSIONS We found no evidence of adverse effects of daily egg ingestion on any cardiac risk factors in adults with CAD over a span of 6 weeks Although visit-to-visit variability in systolic blood pressure ( BP ) is a strong predictor of stroke , the impact on subsequent major adverse cardiac events ( MACEs ) in patients with coronary artery disease ( CAD ) in terms of secondary prevention remains unclear . The aim of this study was to clarify the prognostic significance of visit-to-visit variability  in systolic BP  on subsequent MACE in hypertensive patients with CAD . In the Heart Institute of Japan C and esartan R and omised Trial for Evaluation in Coronary Artery Disease , a total of 2,049 hypertensive patients with CAD were enrolled . Incidence of MACEs in addition to biochemistry tests and office BP were determined during follow-up . Achieved BP was defined as the mean value of systolic BP in patients who did not experience MACE and the mean value of systolic BP before MACE in those who experienced MACE during follow-up . In the present study , 1,734 patients had multiple follow-up visits ( ≥3 times ) until their final follow-up . During a median follow-up of 4.2 years , the primary outcome occurred in 317 patients ( 18.3 % ) . Visit-to-visit variability of systolic BP was defined as the SD . Participants were divided into equal quartiles based on the mean systolic BP during follow-up and visit-to-visit variability of systolic BP , respectively . Although there was no relation between visit-to-visit variability of systolic BP and the incidence of MACE , the highest quartile based on mean systolic BP showed a significant relation with subsequent MACE . In conclusion , in hypertensive patients with CAD , inadequate BP control is a strong predictor of subsequent MACE , whereas visit-to-visit variability of systolic BP is not When observed in elderly hypertensive patients , increased pulse pressure ( PP ) and arterial stiffness are known to be independent risk factors for cardiovascular diseases . Increased systolic blood pressure ( SBP ) leads to left ventricular hypertrophy , while decreased diastolic blood pressure ( DBP ) results in decreased coronary circulation . It is known that increased arterial stiffness is the major cause of increased PP . Thus basic morbid states of cardiac failure or ischemic heart diseases are more likely to develop in elderly hypertensive patients with increased PP and arterial stiffness , and there is need of antihypertensive drugs that decrease these effects in elderly hypertensives . In this study , we compared the effects of an angiotensin-receptor blocker ( ARB : valsartan ) , an angiotensin-converting enzyme inhibitor ( ACE-I : temocapril ) , and long-acting Ca antagonists ( L- and N-type Ca channel blocker : cilnidipine ; and L-type Ca channel blocker : nifedipine CR ) on PP and arterial stiffness measured by pulse wave velocity in elderly hypertensive patients for 3 months . The ARB yielded the largest reductions in PP and brachial-ankle pulse wave velocity ( baPWV ) , followed by the ACE-I and L- and N-type Ca channel blocker , while the L-type Ca channel blocker yielded no improvement . The effects on arterial stiffness and PP thus varied among the drug characteristics . Although ARB achieved the largest reduction in baPWV , this decrease was not associated with any reductions in PP , SBP , DBP , or mean blood pressure , as were the baPWV-decreases achieved by the other drugs , suggesting that ARB may further reduce the risk of arteriosclerosis in elderly hypertensive patients by decreasing arterial stiffness in addition to its antihypertensive effect CONTEXT The effect of antihypertensive drugs on cardiovascular events in patients with coronary artery disease ( CAD ) and normal blood pressure remains uncertain . OBJECTIVE To compare the effects of amlodipine or enalapril vs placebo on cardiovascular events in patients with CAD . DESIGN , SETTING , AND PARTICIPANTS Double-blind , r and omized , multicenter , 24-month trial ( enrollment April 1999-April 2002 ) comparing amlodipine or enalapril with placebo in 1991 patients with angiographically documented CAD ( > 20 % stenosis by coronary angiography ) and diastolic blood pressure < 100 mm Hg . A sub study of 274 patients measured atherosclerosis progression by intravascular ultrasound ( IVUS ) . INTERVENTIONS Patients were r and omized to receive amlodipine , 10 mg ; enalapril , 20 mg ; or placebo . IVUS was performed at baseline and study completion . MAIN OUTCOME MEASURES The primary efficacy parameter was incidence of cardiovascular events for amlodipine vs placebo . Other outcomes included comparisons of amlodipine vs enalapril and enalapril vs placebo . Events included cardiovascular death , nonfatal myocardial infa rct ion , resuscitated cardiac arrest , coronary revascularization , hospitalization for angina pectoris , hospitalization for congestive heart failure , fatal or nonfatal stroke or transient ischemic attack , and new diagnosis of peripheral vascular disease . The IVUS end point was change in percent atheroma volume . RESULTS Baseline blood pressure averaged 129/78 mm Hg for all patients ; it increased by 0.7/0.6 mm Hg in the placebo group and decreased by 4.8/2.5 mm Hg and 4.9/2.4 mm Hg in the amlodipine and enalapril groups , respectively ( P<.001 for both vs placebo ) . Cardiovascular events occurred in 151 ( 23.1 % ) placebo-treated patients , in 110 ( 16.6 % ) amlodipine-treated patients ( hazard ratio [ HR ] , 0.69 ; 95 % CI , 0.54 - 0.88 [ P = .003 ] ) , and in 136 ( 20.2 % ) enalapril-treated patients ( HR , 0.85 ; 95 % CI , 0.67 - 1.07 [ P = .16 ] . Primary end point comparison for enalapril vs amlodipine was not significant ( HR , 0.81 ; 95 % CI , 0.63 - 1.04 [ P = .10 ] ) . The IVUS sub study showed a trend toward less progression of atherosclerosis in the amlodipine group vs placebo ( P = .12 ) , with significantly less progression in the subgroup with systolic blood pressures greater than the mean ( P = .02 ) . Compared with baseline , IVUS showed progression in the placebo group ( P<.001 ) , a trend toward progression in the enalapril group ( P = .08 ) , and no progression in the amlodipine group ( P = .31 ) . For the amlodipine group , correlation between blood pressure reduction and progression was r = 0.19 , P = .07 . CONCLUSIONS Administration of amlodipine to patients with CAD and normal blood pressure result ed in reduced adverse cardiovascular events . Directionally similar , but smaller and nonsignificant , treatment effects were observed with enalapril . For amlodipine , IVUS showed evidence of slowing of atherosclerosis progression OBJECTIVES The purpose of this study was to determine the prognostic accuracy of electron beam computed tomographic ( CT ) scanning of the coronary arteries and the relationship of coronary calcification to st and ard coronary disease risk factors and C-reactive protein ( CRP ) in the prediction of atherosclerotic cardiovascular disease ( ASCVD ) events in apparently healthy middle-age persons . BACKGROUND As a screening test for coronary artery disease ( CAD ) , electron beam CT scanning remains controversial . METHODS In a prospect i ve , population -based study , 4,903 asymptomatic persons age 50 to 70 years underwent  electron beam CT scanning of the coronary arteries . RESULTS At 4.3 years , follow-up was available in 4,613 participants ( 94 % ) , and 119 had sustained at least one ASCVD event . Subjects with ASCVD events had higher baseline coronary calcium scores ( median [ interquartile range ] , Agatston method ) than those without events : 384 ( 127 , 800 ) versus 10 ( 0 , 86 ) ( p < 0.0001 ) . For coronary calcium score threshold > or = 100 versus < 100 , relative risk ( 95 % confidence interval ) was 9.6 ( 6.7 to 13.9 ) for all ASCVD events , 11.1 ( 7.3 to 16.7 ) for all CAD events , and 9.2 ( 4.9 to 17.3 ) for non-fatal myocardial infa rct ion and death . The coronary calcium score predicted CAD events independently of st and ard risk factors and CRP ( p = 0.004 ) , was superior to the Framingham risk index in the prediction of events ( area under the receiver-operating characteristic curve of 0.79 + /- 0.03 vs. 0.69 + /- 0.03 , p = 0.0006 ) , and enhanced stratification of those falling into the Framingham categories of low , intermediate , and high risk ( p < 0.0001 ) . CONCLUSIONS The electron beam CT coronary calcium score predicts CAD events independent of st and ard risk factors , more accurately than st and ard risk factors and CRP , and refines Framingham risk stratification H igh and rogen levels in men have been regarded as a risk factor for coronary artery disease ( CAD ) . However , it has recently been demonstrated that supplements of and rogens inhibit atheroma formation in castrated male animals , suggesting that testosterone may be antiatherosclerotic . In men with angina pectoris , a significant inverse correlation was found between plasma testosterone levels and the extent of CAD , demonstrating that low testosterone levels could be a risk factor for CAD . Other reports suggest that testosterone replacement therapy in men with CAD has a beneficial effect on angina pectoris and exercise-induced ST-segment depression . Another study showed that testosterone enhanced endotheliumindependent coronary artery dilation and flow-mediated brachial arterial vasoreactivity in men with CAD . In this study , we assessed the effects of oral testosterone administration on brachial arterial vasoreactivity in men with CAD . • • • Thirty-five men ( aged 58 8 years ) with CAD were r and omized to placebo ( n 17 ) or treatment group ( n 18 ) . Demographics of the study group are summarized in Table 1 . Diagnostic criteria of CAD are a history of unstable and stable angina pectoris with angiographic evidence ( 50 % stenosis of lumen diameter ) . Exclusion criteria were inflammatory disease or malignancy , ejection fraction 45 % , clinical evidence of heart failure , and Q-wave myocardial infa rct ion within 3 months before the study . The treatment group completed oral administration of 160 mg of testosterone undecanoate ( And riol , N.V. Organon , Oss , The Netherl and s ) daily for 4 weeks followed by 80 mg testosterone undecanoate for 8 weeks , in addition to their current medication . Using high-resolution ultrasound , we assessed brachial arterial vasoreactivity to reactive hyperemia ( flow-mediated dilation ) and sublingual nitroglycerin ( nitroglycerin-mediated dilation ) at baseline and after 12 weeks of treatment . Patients taking nitrates discontinued therapy 24 hours before the study to avoid nitrate tolerance . A 10-MHz linear phased-array ultrasound transducer ( GE Vigmed Ultrasound , Horten , Norway ) was used to image the dominant arm brachial artery longitudinally 3 to 5 cm just above the antecubital fossa . All patients rested in the supine position for 10 minutes in a quiet room . After the depth and gain setting were optimized to identify the vessel wall , the brachial artery diameter was measured from the anterior to the posterior interface between the media and the adventitia and determined at end-diastole on B mode . Reactive hyperemia was induced by inflation and then deflation of a pneumatic cuff placed around the upper arm . The blood pressure cuff was inflated to 250 mm Hg for 5 minutes . After release of the cuff , brachial artery diameter was measured within the first 15 seconds of reactive hyperemia . The brachial artery was allowed to return to the baseline level until 10 minutes after cuff release . Then , a further baseline brachial artery diameter was obtained . Nitroglycerin , 0.6 mg , was then given sublingually , and the brachial artery diameter was measured for the ensuing 3 minutes . The percent change in diameter caused by reactive hyperemia was calculated by dividing the difference from baseline end-diastolic diameter by the baseline value . The percent change in diameter caused by nitroglycerin administration was also calculated in the same way . Blood pressure and heart rate were measured before the examination . All data were calculated as an average of 4 consecutive cardiac cycles . Early morning blood sampling for fasting lipid profiles was performed and plasma-free testosterone levels were obtained immediately before ultrasound imaging and 12 weeks later . A st and ard radioimmunoassay method was used for analysis ( DSL-4900 kit , Diagnostic System Laboratory Inc. , Houston , Texas ) . All descriptive data are presented as mean SD and analyzed using SPSS for Windows 9.0 ( SPSS Inc. , Chicago , Illinois ) From the Cardiology Division , Yonsei Cardiovascular Center and Cardiovascular Research Institute , College of Medicine , Seoul ; and Department of Food and Nutrition , College of Ecology , Yonsei University , Seoul , South Korea . Dr. Jang ’s address is : Cardiology Division , Yonsei Cardiovascular Center , Yonsei University College of Medicine , 134 , Shinchon-Dong , Seodaemun-Gu , Seoul 120 - 752 , South Korea . E-mail : jangys1212@yumc.yonsei.ac.kr . Manuscript received August 10 , 2001 ; revised manuscript received and accepted December 10 , 2001 . TABLE 1 Clinical Characteristics of Study
These results suggest that reducing DBP to 80 mmHg or less would significantly reduce coronary revascularization and heart failure but at the expense of causing hypotension in CAD patients .
The target of diastolic blood pressure ( DBP ) remains controversial in patients with coronary artery disease ( CAD ) .