AHA Blood Pressure Goals in Coronary Artery Disease
For adults with established coronary artery disease, the 2017 ACC/AHA guideline recommends a blood pressure target of <130/80 mm Hg (Class I recommendation). 1
Blood Pressure Target
Target BP <130/80 mm Hg is the recommended goal for all patients with stable ischemic heart disease (SIHD), based on evidence showing a 25% reduction in cardiovascular complications and 27% reduction in all-cause mortality when systolic BP is reduced to <130/80 mm Hg in high-risk patients. 1
This target applies regardless of whether the patient has had a prior myocardial infarction, has stable angina, or has other manifestations of coronary disease. 1
Initial Antihypertensive Regimen
First-line therapy should include medications with compelling indications for coronary disease:
For Patients with Prior MI or Acute Coronary Syndrome
Beta-blocker + ACE inhibitor or ARB as the foundation of therapy (Class I recommendation). 1, 2
Beta-blockers should be continued for at least 3 years post-MI; continuation beyond 3 years is reasonable for long-term hypertension management (Class IIa). 1
For Patients with Stable Angina
Beta-blocker + ACE inhibitor or ARB as first-line agents (Class I recommendation). 1
If angina persists and BP remains uncontrolled despite beta-blocker therapy, add a dihydropyridine calcium channel blocker (e.g., amlodipine, extended-release nifedipine) to the beta-blocker (Class I recommendation). 1
Additional Agents for Uncontrolled BP
When BP remains ≥130/80 mm Hg despite initial therapy, add thiazide diuretics and/or mineralocorticoid receptor antagonists (e.g., spironolactone) to achieve target. 1
Dihydropyridine CCBs can be safely combined with beta-blockers and are particularly useful when additional BP lowering is needed. 1
Treatment Initiation Strategy
Stage 1 hypertension (130–139/80–89 mm Hg): Start with a single agent (beta-blocker or ACE inhibitor/ARB based on compelling indication), then add a second agent from a different class if needed. 2
Stage 2 hypertension (≥140/90 mm Hg or >20/10 mm Hg above goal): Initiate with a two-drug combination immediately, preferably as a single-pill formulation. 2, 3
Critical Caveats for CAD Patients
Diastolic Blood Pressure J-Curve
Avoid lowering diastolic BP below 60 mm Hg in patients with CAD, as excessive diastolic reduction may impair coronary perfusion and increase myocardial ischemia risk. 1, 2, 4
The optimal diastolic range is 70–79 mm Hg; when systolic BP is at target (<130 mm Hg) but diastolic remains ≥80 mm Hg, cautiously intensify therapy to achieve diastolic 70–79 mm Hg. 1, 2
Coronary perfusion occurs predominantly during diastole, and in the setting of left ventricular hypertrophy and coronary stenosis, autoregulation may be exhausted at low diastolic pressures. 4
Agents to Avoid
Never combine an ACE inhibitor with an ARB (or add a direct renin inhibitor), as this increases hyperkalemia and acute kidney injury risk without cardiovascular benefit. 2, 5
Beta-blockers should not be used as first-line therapy in CAD patients >3 years post-MI without angina or heart failure, as they are less effective than other classes for stroke prevention in uncomplicated hypertension. 2
Monitoring
Monthly follow-up after initiating or adjusting therapy until BP target is achieved. 2, 3, 5
When prescribing ACE inhibitors, ARBs, or diuretics, check serum creatinine, eGFR, and potassium within 1–2 weeks of initiation, after each dose increase, and annually thereafter. 2
An increase in creatinine up to 50% above baseline or to 3 mg/dL (whichever is greater) is acceptable. 2
Evidence Strength
The <130/80 mm Hg target carries Class I, Level B-R evidence for systolic and Class I, Level C-EO evidence for diastolic targets. 1 The recommendation for beta-blockers and ACE inhibitors/ARBs as first-line therapy in CAD is based on their proven benefit in reducing recurrent MI, cardiovascular death, and heart failure in this population (Class I, Level B-R). 1