Features August 2016 Issue

Combination Therapy May Be Best for Intermediate Heart Disease Risks

Research shows that adding a cholesterol-lowering drug may have a significant effect on individuals who have high blood pressure but are not yet considered high-risk patients.

We don’t tend to think of statins as antihypertensive medications, because they are designed to lower LDL cholesterol, not blood pressure. But recent research suggests that for many patients with high blood pressure, adding statins to their anti-hypertensive medication regimen may make a huge difference.

In the Heart Outcomes Prevention Evaluation-3 (HOPE-3) trial, researchers explored various combinations of anti-hypertensive and cholesterol-lowering drugs among individuals considered to be at intermediate risk of coronary heart disease (CHD). One of the main findings was that the combination of statin therapy and anti-hypertensive therapy signficantly lowered the risk of cardiovascular events, such as heart attack and stroke, among intermediate-risk patients with high blood pressure.

Leslie Cho, MD, co-director of Preventive Cardiology and Rehabilitation at Cleveland Clinic, says the HOPE-3 results are important in underscoring the benefits of statin therapy. She also noted that the study reaffirmed the importance of getting blood pressure below 140/90 mm Hg. HOPE-3, however, didn’t suggest that aggressive anti-hypertensive therapy (getting systolic pressure below 120 mm Hg)was necessary for intermediate-risk individuals.

“For intermediate-risk patients, statins really lower event rates,” Dr. Cho says, adding that it’s important for everyone to discuss their cardiovascular risks with their doctor.

“It is important to assess your risk and take action,” she says. “Not knowing and not doing something is an active choice. Just because you don’t know your risk does not mean that you have no risk.”

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Research supports combining statins and anti-hypertensive medications if you’re at intermediate risk of heart disease.

Controlling Your Blood Pressure

Another key finding from HOPE-3, according to Dr. Cho, was that a reasonable and realistic blood pressure goal provided intermediate-risk patients similar protective benefits as lower, often harder-to-reach targets.

Unlike the SPRINT trial, which garnered a lot of attention in 2015 because its findings supported aggressive therapy to drive systolic pressure below 120 mm Hg, the HOPE-3 trial didn’t focus on high-risk patients. Intermediate-risk patients didn’t experience significantly lower event risks with aggressive anti-hypertensive therapy in this recent study.

“HOPE-3 showed that these patients should try to keep their blood pressure under 140/90, but we don’t have to go overboard and get it down too low,” Dr. Cho says. “There is no benefit in getting someone to “normal” 120/80. This is an important finding because it validates what we have suspected but never really studied. Taking someone with pre-hypertension and lowering them to ‘normal’ does not help.”

Prehypertension is defined as a systolic presure of 120 to 139 mm Hg or a diastolic pressure of 80 to 89 mm Hg.

Why Combination Therapy Works for Heart Disease Risks

Certainly managing your blood pressure with the help of anti-hypertensive medications may help you avoid cardiovascular events and other health complications down the road. But why might statins have such a dramatic impact on your event risks?

Evidence continues to mount that statin therapy has a profound and direct effect on your risk of heart attack, stroke or other cardiovascular problems, such as peripheral artery disease. Statins can help slow the progression of atherosclerosis—the buildup of plaque (cholesterol, fats, and other substances) along artery walls. Research is also ongoing to study whether aggressive statin therapy may be able to significantly reverse plaque formation.

When arteries in the heart (coronary arteries) narrow to the point where blood flow stops or is severely restricted, the result is a heart attack. Poor blood flow to the brain can result in a stroke. Narrowed arteries elsewhere in the body can lead to muscle pain and other problems.

A heart-healthy diet, regular exercise and other good lifestyle choices can go a long way in helping to keep atherosclerosis at bay. But for many people, statins or other cholesterol-lowering drugs can make a major difference in preventing or at least delaying cardiovascular events later in life.

For people with high blood pressure, such as those in the HOPE-3 trial, their arteries are already at risk. Hypertension puts a strain on arteries, stiffening them and increasing the risk of atherosclerosis. Combination therapy, including statins and anti-hypertensive drugs, can help these patients. The researchers noted that giving blood pressure-lowering drugs to patients with normal blood pressure but high cholesterol did not have the same protective benefits as putting hypertensive patients on statins.

Looking Ahead

The American College of Cardi­ology (ACC) is expected to update its blood pressure management guidelines in 2017, so with the findings of SPRINT and HOPE-3, there may be some shifts in how various patient groups are treated.

However, Dr. Cho says she doubts HOPE-3 will dramatically change the way intermediate-risk patients are treated. She notes that the current guidelines issued by the ACC recommend even broader use of statin therapy. However, HOPE-3 does provide solid evidence to support the approach many cardiologists take with certain patients.

“I think this reinforces what we have been thinking regarding cholesterol lowering and the benefit of statins in this intermediate group,” Dr. Cho says.

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