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Blood pressure targets

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To the Editor: In their review, 1Thomas et al noted that the benefits of intensive blood pressure lowering seen in the SPRINT study 2 were not observed in the Action to Control Cardiovascular Risk in Diabetes-Blood pressure (ACCORD BP) trial 3 or in the Secondary Prevention of Small Subcortical Strokes (SPS3) trial. 4 In addition to the reasons discussed in their review, the discrepancy may be due to the surprisingly low rate of statin use in the patients enrolled in SPRINT. Even though 61% of the patients in SPRINT had a 10-year Framingham risk score greater than 15%, only 44% of the patients were on statin therapy. In comparison, rates of statin use in ACCORD BP and SPS3 were 65% and 83%, respectively.

A possible interaction between statin use and intensive blood pressure lowering is consistent with previous data on angiotensin-converting enzyme (ACE) inhibitor use in high-risk populations.

The Heart Outcomes Prevention Evaluation (HOPE) trial, 5 in which only 29% of patients received lipid-lowering therapy, found that ACE inhibitor use was associated with a significant reduction in a composite cardiovascular outcome, whereas the Prevention of Events With Angiotensin-Converting Enzyme Inhibitor Therapy (PEACE) trial, 6 in which 70% of patients were on lipid-lowering therapy, did not show a benefit for ACE inhibitor therapy. In addition, there are many drug interactions between statins and calcium channel blockers, potentially limiting options for simultaneous aggressive treatment of lipid levels and blood pressure.

In summary, aggressive use of statins may confer sufficient cardiovascular protection when aggressive antihypertensive therapy provides little or no incremental benefit. Hopefully, further analyses of these trials will shed light on this important question.

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