Context Hypertension guidelines advocate treating systolic blood pressure (BP) to less than 130 mm Hg for patients with diabetes mellitus; however, data are lacking for the growing population who also have coronary artery disease (CAD). Objective To determine the association of systolic BP control achieved and adverse cardiovascular outcomes in a cohort of patients with diabetes and CAD. Design, Setting, and Patients Observational subgroup analysis of 6400 of the 22 576 participants in the International Verapamil SR-Trandolapril Study (INVEST). For this analysis, participants were at least 50 years old and had diabetes and CAD. Participants were recruited between September 1997 and December 2000 from 862 sites in 14 countries and were followed up through March 2003 with an extended follow-up through August 2008 through the National Death Index for US participants. Intervention Patients received first-line treatment of either a calcium antagonist or β-blocker followed by angiotensin-converting enzyme inhibitor, a diuretic, or both to achieve systolic BP of less than 130 and diastolic BP of less than 85 mm Hg. Patients were categorized as having tight control if they could maintain their systolic BP at less than 130 mm Hg; usual control if it ranged from 130 mm Hg to less than 140 mm Hg; and uncontrolled if it was 140 mm Hg or higher. Main Outcome Measures Adverse cardiovascular outcomes, including the primary outcomes which was the first occurrence of all-cause death, nonfatal myocardial infarction, or nonfatal stroke. Results During 16 893 patient-years of follow-up, 286 patients (12.7%) who maintained tight control, 249 (12.6%) who had usual control, and 431 (19.8%) who had uncontrolled systolic BP experienced a primary outcome event. Patients in the usual-control group had a cardiovascular event rate of 12.6% vs a 19.8% event rate for those in the uncontrolled group (adjusted hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.25–1.71; P<.001). However, little difference existed between those with usual control and those with tight control. Their respective event rates were 12.6% vs 12.7% (adjusted HR, 1.11; 95% CI, 0.93–1.32; P=.24). The all-cause mortality rate was 11.0% in the tight-control group vs 10.2% in the usual-control group (adjusted HR, 1.20; 95% CI, 0.99–1.45; P=.06); however, when extended follow-up was included, risk of all-cause mortality was 22.8% in the tight control vs 21.8% in the usual control group (adjusted HR, 1.15; 95% CI, 1.01–1.32; P=.04). Conclusion Tight control of systolic BP among patients with diabetes and CAD was not associated with improved cardiovascular outcomes compared with usual control.

THE JOurNaL Of CLiNiCaL HypErTENsiON 295Brachial systolic and pulse blood pressures (BPs) 1 Numerous observational epidemiology studies and clinical trials have shown a strong positive, continuous, and graded association between brachial artery systolic and/or pulse Bp and CV risk and adverse events in individuals older than 50 years. 2 arterial diastolic Bp has been found to be inversely (or negatively) related to coronary artery disease (CaD) and CV mortality. 2 in some large studies, the association of diastolic Bp with all-cause and CV mortality is reported as J-or u-shaped in elderly participants. 3 CV disease and outcome are also related to invasively measured central aortic pulse Bp, the pressure exerted on the heart, brain, and kidneys. 4 since central systolic and pulse Bp are related to changes in arterial effects 5 and can be measured easily, accurately, and noninvasively using a validated generalized transfer function and pulse wave analysis, 6 attention has been directed toward arterial stiffness, pulse wave velocity (pWV), and wave reflections as independent CV risk factors that predict adverse events and relate to outcome. 4,7 independent studies have R e v i e w P a p e r •