Abstract-TheA dults with diabetes are 2 to 4ϫ more likely to die from heart disease and stroke than those without diabetes. This risk increases for adults with hypertension (HT) and diabetes. 1 To reduce cardiovascular risk in those with diabetes, more aggressive blood pressure (BP) control is needed compared with the general population. The sixth report of the Joint National Committee (JNC VI) recommended a target BP of Ͻ130/85 mm Hg for persons with diabetes, and the seventh report (JNC 7) recommends a target of Ͻ130/80 mm Hg. 2,3 Postmyocardial infarction studies demonstrate that ␤-blockers and diuretics, alone or in combination, reduce cardiovascular mortality in coronary artery disease (CAD), with ␤-blockers being preferred. 2,4 However, use of ␤-blockers or diuretics is associated with metabolic abnormalities, including impaired glucose tolerance, insulin resistance and hypokalemia, and increased risk for new-onset diabetes. [5][6][7][8][9] Nondihydropyridine calcium antagonists (non-DHPCAs) such as verapamil SR are recommended as an alternative to ␤-blockers for angina relief in persons with CAD-HT. 2,3 Verapamil SR effectively reduces BP 10 and clinical outcomes in patients with CAD. 11 Moreover, non-DHPCAs are generally considered metabolically neutral. 7,10 Previous outcome studies evaluated the effect of BP reduction with different antihypertensive medications in a cohort of established CAD and HT but without concomitant use of renin-angiotensin system (RAS) blockers (ie, angiotensin-converting enzyme [ACE] inhibitors and angiotensin receptors blockers [ARBs]) and lower BP goals. The INternational VErapamil SR-Trandolapril study (INVEST) evaluated 2 recommended antihypertensive regimens in a CAD-HT population, 2 with the option of adding an ACE inhibitor or hydrochlorothiazide (HCTZ), to achieve JNC VI BP targets. 12 This prespecified analysis reports outcomes in the cohort with diabetes.

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In hypertensive patients with CAD, increased risk for adverse outcomes was associated with conditions related to the severity of CAD and diminished left ventricular function. Lower follow-up BP and addition of trandolapril to verapamil SR each were associated with reduced risk.

for the Reduction of Atherothrombosis for Continued Health (REACH) Registry InvestigatorsBackground-Studies report a protective effect of higher attained educational level (AEL) on cardiovascular outcomes.However, most of these studies have been conducted in high-income countries (HICs) and lack representation from lowand middle-income countries (LMICs), which bear Ͼ80% of the global burden of cardiovascular disease. Methods and Results-The Reduction of Atherothrombosis for Continued Health (REACH) Registry is a prospective study of 67 888 subjects with either established atherothrombotic (coronary, cerebrovascular, and/or peripheral arterial) disease or multiple atherothrombotic risk factors enrolled from 5587 physician practices in 44 countries. At baseline, AEL (0 to 8 years, 9 to 12 years, trade or technical school, and university) was self-reported for 61 332 subjects. Outcomes included the baseline prevalence of atherothrombotic risk factors and the rate of incident cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) through 23 months across AEL groups, stratified by sex and world region (LMICs or HICs). Educational attainment was inversely associated with age and diabetes mellitus and directly associated with hypercholesterolemia in all subjects. However, for other risk factors such as obesity, smoking, hypertension, and baseline burden of vascular disease, AEL was protective (inversely associated) in HICs but not protective in LMICs. The protective effect of greater AEL on incident cardiovascular events was strongest in men from HICs (PϽ0.0001), more modest in women from HICs (Pϭ0.0026) and in men from LMICs (Pϭ0.082), and essentially absent in women from LMICs (Pϭ0.32). Conclusion-In contrast to HICs, higher AEL may not be protective against cardiovascular events in LMICs, particularly in women. (Circulation. 2010;122:1167-1175.)

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