Impact of Hypertension in Patients with Atrial Fibrillation and Importance of Blood Pressure Management during Anticoagulation Therapy
1)Department of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
2)Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
3)Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
Hypertension is a well-known risk factor for cardiovascular diseases. In addition, since hypertension is associated with the development of electrical and structural remodeling of atrial myocardium, control of blood pressure (BP) is important to prevent new-onset atrial fibrillation (AF). In patients presenting with AF during anticoagulation therapy, hypertension is a risk factor for both thromboembolism and hemorrhagic complications, especially intracranial hemorrhage (ICH). Therefore, strict BP control is required to reduce, or at least not to increase, the risk of both events. In the Japanese Guidelines for the Management of Hypertension 2014 (JSH2014), a BP of less than 130/80 mmHg is currently recommended to reduce the risk of ICH, based on the results of the Bleeding with Antithrombotic Therapy (BAT) study. However, because the BAT study was observational and included patients without AF, a true appropriate target BP for patients with AF during anticoagulation therapy remains uncertain. Therefore, we have reviewed the influence of hypertension and BP control on adverse outcomes in the subanalyses of the J-RHYTHM Registry, the Fushimi AF Registry, and the phase III clinical trials of non-vitamin K antagonist oral anticoagulants (NOACs). In the J-RHYTHM Registry, hypertension was an independent risk factor for major hemorrhage (hazard ratio [HR] 1.52, 95% confidence interval [CI] 1.05〜2.21). The BP at baseline was not associated with any event, whereas the highest quartile of systolic BP (≥136 mmHg) at the time closest to the event or at the end of the follow-up was significantly associated with the incidence of thromboembolism (odds ratio [OR] 2.88, 95% CI 1.75〜4.74) and major hemorrhage (OR 1.61, 95% CI 1.02〜2.53). In the Fushimi AF Registry, although hypertension was not a significant risk for any event, the incidence of stroke/systemic embolism (SE) and major bleeding was significantly higher in patients with uncontrolled hypertension (systolic BP ≥150 mmHg) than in those without hypertension (HR 1.74, 95% CI 1.08〜2.53 for stroke/SE; HR 2.01, 95% CI 1.21〜3.23 for major bleeding). In the phase III trials of NOACs, hypertension was significantly associated with major hemorrhage in the RE-LY trial and with stroke/SE in the ROCKET-AF and ARISTOTLE trials. Although no specific target BP could be determined from these studies, it is consistent that the incidence rates were higher in patients with uncontrolled hypertension than in those with controlled BP or without hypertension. A decrease in the risk of adverse events can be expected if BP is appropriately controlled in patients with AF during anticoagulation therapy.
日医大医会誌 2019; 15(1), 12-23
hypertension, atrial fibrillation, anticoagulation, thromboembolism, hemorrhage
Eitaro Kodani, MD, PhD, Department of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama Tokyo 206-8512, Japan