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Peripheral Arterial Disease and Isolated Systolic Hypertension: the ATTEST Study

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Peripheral Arterial Disease and Isolated Systolic Hypertension: the ATTEST Study Journal of Human Hypertension (2009) 23, 182–187 & 2009 Macmillan Publishers Limited All rights reserved 0950-9240/09 $32.00 www.nature.com/jhh ORIGINAL ARTICLE Peripheral arterial disease and isolated systolic hypertension: The ATTEST Study ME Safar1, P Priollet2, F Luizy1, J-J Mourad3, P Cacoub4, H Levesque5, J Benelbaz6, P Michon7, M-A Herrmann8 and J Blacher1 1Faculte´ de Me´decine, Hoˆtel-Dieu hospital, Universite´ Paris Descartes, Paris, France; 2Saint Joseph hospital, Paris, France; 3Avicenne hospital, AP-HP and EA 3412, University Paris, Bobigny, France; 4Pitie´-Salpe´trie`re hospital, AP-HP, University Paris, Paris, France; 5Department of Internal Medicine, Rouen University hospital, 76031 Rouen Cedex, France; 6Issy les Moulineaux, France; 7Sanofi Aventis, Paris, France and 8Bristol-Myers Squibb, Rueil-Malmaison, France Hypertension is a risk factor for cardiovascular (CV) subjects with systolic hypertension were characterized diseases, either coronary artery disease (CAD), periph- by the presence of PAD, with little or no presence of eral artery disease (PAD) or cerebrovascular disease CAD and/or CVD. Subjects with systolic–diastolic (CVD). The relationships between those different locali- hypertension were characterized by the presence of zations of CV disease and the haemodynamic features CAD and/or CVD, but without PAD. Although the of hypertension have been poorly evaluated in the past. former was only influenced by age, dyslipidaemia and In the ATTEST study, a geographically representative diabetes mellitus influenced the latter. This study panel of 3020 general practitioners recruited 8316 confirms the high prevalence of hypertension (80%) in consecutive patients with CV diseases (PAD, CAD or a large population of patients with CV diseases selected CVD, alone or in association). Blood pressure, which in primary care. Analysis of different features of was not an inclusion criterion, was then measured and hypertension revealed that isolated systolic hyperten- related to the different forms of CV diseases. Blood sion was the most prevalent form of hypertension in pressure classification involved 20% normotensive this treated population. Finally, one of the predominant subjects, 24% subjects with controlled hypertension, goals of secondary prevention in subjects with 42% subjects with isolated systolic hypertension and PAD should be the treatment of isolated systolic 14% subjects with systolic–diastolic hypertension, all hypertension. hypertensives with or without antihypertensive therapy. Journal of Human Hypertension (2009) 23, 182–187; From multiple regression analysis, it appeared that doi:10.1038/jhh.2008.121; published online 2 October 2008 Keywords: arteries; peripheral; hypertension; systolic Introduction differ according to the dominant site of CV events.2 For instance, blockers of the renin–angiotensin Cardiovascular disease being the first cause of system might be more efficient in preventing cardiac mortality worldwide, and hypertension being the 1 complications whereas calcium entry blockers could most prevalent cardiovascular risk factor, it is of be more efficient in preventing cerebral complica- paramount importance to study the precise relation- tions.3 Whether the haemodynamic features of ships existing between different forms of hyperten- hypertension, which may either be isolated systolic, sion and different localizations of atherosclerosis. isolated diastolic or systolic–diastolic, have a part in During antihypertensive drug therapy in patients the therapeutic indications, has not yet been clearly with previous cardiovascular (CV) event, the goal of investigated. treatment is to avoid the recurrence of CV events, When the clinical aspects of end-organ damage particularly those observed in the cerebral, cardiac are considered in hypertensive subjects, an in- or renal circulations as well as in the lower limbs. creased incidence of systolic hypertension is The results of meta analysis indicate nowadays that particularly observed in subjects with cerebrovas- the prescriptions of antihypertensive agents might cular complications and, more recently, in subjects with chronic renal disease.4 In patients with peripheral artery disease (PAD), systolic–diastolic Correspondence: Professor J Blacher, Centre de Diagnostic et de hypertension is not frequently observed but the The´rapeutique, Hoˆpital Hoˆtel-Dieu, AP-HP; 1 Place du Parvis repartition of subjects between normotensives and Notre-Dame 75004 Paris, France. isolated systolic hypertensives has not been exten- E-mail: [email protected] 2 Received 11 June 2008; revised 4 August 2008; accepted 24 sively investigated. In coronary heart disease, it is August 2008; published online 2 October 2008 classically observed that, following myocardial Arterial disease and hypertension ME Safar et al 183 infarction, the incidence of increased systolic blood circulation and abdominal aortic aneurysm). CAD pressure (SBP) is markedly reduced.2,4 Thus, it is was defined as any history of angina pectoris (chest important, in a large population of hypertensive pain precipitated by exertion and relieved by rest or subjects with CV end-organ damage, to evaluate the nitrates) confirmed by coronary angiography, incidence of normal blood pressure (BP), systolic– myocardial infarction, typical sequelae on electro- diastolic hypertension and isolated systolic hyper- cardiography, coronary percutaneous transluminal tension according to the various sites of CV events. angioplasty, or coronary artery bypass surgery or a The objectives of the ATTEST study (‘prise en combination. CVD was defined by history of charge de l’ArTe´riopaThie oblitErante des membreS ischaemic stroke confirmed by computed tomo- infe´rieurs chez les paTients en me´decine ge´ne´rale’)5 graphy or magnetic resonance imaging. were to compare pharmacological treatment (pri- A physician-completed inclusion questionnaire mary objective) and medical management, including contained the following data: gender, age, weight, cardiovascular tests and physician’s assessment of height, personal history of diabetes mellitus, dysli- future cardiovascular and amputation risks (second- pidaemia, or hypertension, current and previous ary objectives) of patients with established PAD to smoking habit, CV tests previously performed, and patients with other vascular site(s) involved in current use of antiplatelet, antihypertensive, lipid- atherothrombosis. The objective of the analysis of lowering and antidiabetic drugs. These medical data the ATTEST study presented in the present paper is were not obtained from a formal testing protocol, to compare the prevalence of the different varieties and the ATTEST study was not planned to add any of hypertension as systolic–diastolic hypertension tests to the management of the patients. Rather, and isolated systolic hypertension and to determine physicians were asked to give the most precise which category of atherosclerotic CV events may information present in their medical files. Diabetes affect the heart, the brain and the lower limbs, mellitus was diagnosed on the basis of plasma respectively with regard to these varieties. glucose 47.0 mmol lÀ1 and/or antidiabetic treat- ment. Dyslipidaemia was defined on the basis of guidelines that prevailed at the time of inclusion 6 Materials and methods and/or presence of hypolipidaemic treatment. Population The design of the ATTEST study has been reported BP classification elsewhere.5 Briefly, this investigation was an ob- Blood pressure was measured after a 5-min rest. servational, cross-sectional, epidemiologic study Different devices were used according to the device that took place in France between April and generally used by the practitioner, and the mean of November 2003. Patients were selected by a geo- three determinations was considered as systolic (S) graphically representative panel of 3020 general and diastolic (D) BP. Pulse pressure was calculated practitioners who agreed to participate. Each physi- as PP ¼ SBP–DBP. Mean blood pressure was cian was asked to include the first three patients MBP ¼ DBP þ 1/3 PP. identified from his or her practice to fulfill the Based on these measurements and on question- inclusion criteria. These criteria were patients (1) naires (previous diagnosis of hypertension), the BP 418 years old, (2) with at least one site of proven classification was composed of four groups (Table 1): atherosclerotic CV disease: PAD of the lower limbs for two patients, and proven coronary artery disease Normotensives (potentially receiving cardio- (CAD) or cerebrovascular disease (CVD) for the third vascular drugs with antihypertensive effects patient and who were (3) willing to participate in such as b-blockersy): SBPo140 mm Hg and DBP the study and give consent after receiving written o90 mm Hg (n ¼ 1687) and oral information. A total of 8316 patients were Controlled hypertensives (receiving antihyper- included (all data completed) and analyzed. The tensive drugs): SBPo140 mm Hg and DBPo protocol was approved by the institutional review 90 mm Hg (n ¼ 2018) committees ‘Conseil National de l’Ordre des Me´decins’, Isolated systolic hypertension, with SBPX ‘Comite´ Consultatif sur le Traitement de l’Information 140 mm Hg and DBPo90 mm Hg (n ¼ 3480) en Matie`re de Recherche dans le domaine de la Sante´’, Systolic–diastolic hypertension, with SBPX ‘Commission Nationale Informatique et Liberte´’, Paris, 140 mm Hg and DBPX90 mm Hg (n ¼ 1131). France. Atherosclerotic diseases were defined using the Subjects
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